Register

Husband First Name Last Name

Date of Birth

Cell Phone # Format: 555-456-7890 Email Address Street Address City State Zip Gender

Wife First Name Last Name

Date of Birth

Cell Phone # Format: 555-456-7890 Email Address

Mailing Address same as Husband?

Gender

Childcare Do you need childcare?

Yes No

# of Children?

Participating Programs Select Programs You Participate in:

None WIC TANF Unemployment "Step Up" School Lunches

Bring proof of participation in at least one of those programs and payment for the child care with them to the first class session.