PEP Registration

Date and time of class requested

Name *

First

Last

Email *

Permission to email relevant information regarding registration for the Parenting Education Class *

Phone *

Permission to call number for reminder calls or relevant information regarding registration for the Parenting Education Class *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

How did you hear about us?

You have the right to attend class together or separately from your child(ren’s) other parent.

Please check here if you DO NOT want to attend the same class as your child(ren’s) other parent.

What is the other parent’s full name? *

First

Last

Have you and your child(ren’s) other parent had any domestic violence issues or other safety concerns? *

Is there any type of Court Order currently filed against you or your child(ren’s) other parent, such as a restraining order, protective order, or no contact order? *

Please provide the ages and genders of your children *

Why are you seeking Parenting Education Program (PEP) Classes? *

Court Docket # *

Do you have any special needs to assist you in attending the class? *

Yes, I may need assistance to attend the class.
No, I do not need assistance to attend the class.

Please specify so we can make the appropriate accommodations *

Do you need a class taught in Spanish? *

Did the Court provide you with a fee waiver for this class? *

Please upload a copy of the court waiver. *

Click or drag a file to this area to upload.

By checking this box, you agree that you have read and understand the following: I understand that filling out this form does not guarantee me a spot in any specific Parenting Education Program (PEP) Class. You should receive a confirmation of payment and notification of your completed registration. If the requested class is not available, you will be provided with alternative classes by phone or email. The class fee of $150 is due in advance. We accept credit cards, cash and electronic payments via Venmo or PayPal. Thank you.

I have read and understand the above and I agree. *

Payment Options

$150.00 payment is due prior to the first class. If full payment is not made during registration, you will not be able to attend the class and will have to register for another class segment. We do not accept partial payments.

Cash Payment

$150.00 cash is due prior to the first class. If full payment is not made at that time, you will not be able to attend the class and will have to register for another class segment. We do not accept partial payments.

Check Payment

$150.00 payable to United Services, with PEP in the memo. This is due prior to the first class. If full payment is not made at that time, you will not be able to attend the class and will have to register for another class segment. We do not accept partial payments. Please send checks to United Services, 1007 North Main Street, Dayville, CT Attention: PEP. All checks much be cleared and processed prior to class.

Venmo Payments

Please label your payment: PEP (you may also want to consider making your payment private) Payment can be made: @unitedservicesofct

Waiver

Please make sure you have uploaded a copy of your waiver above.

PayPal Commerce *

Card Number

Expiration Date

Security Code

Card Holder Name

Multiple Choice