KIDS` TURN PARENT WORKSHOP REGISTRATION FORM

(for office use only) Parent ID ____________
(for parents only) Parent Initials: _____________________
KIDS' TURN PARENT WORKSHOP REGISTRATION FORM
1242 Market Street, 2nd Floor, San Francisco, CA 94102-4802
Phone: (415) 437-0700 or (800) 392-9239; Fax: (415) 437-0796
www.kidsturn.org
[email protected]
This form is to be completed by parents to register themselves for Kids' Turn. EACH PARENT MUST FILL OUT HIS OR HER
OWN REGISTRATION FORM(S). In addition, please complete one child's registration form for each of your children. Each
parent who registers should complete a separate child's registration form for each child. In the event your child's other parent does
not have copies of this registration form, please provide one for him or her, or request that one be sent. This form will not register
your child(ren)'s other parent. PLEASE PRINT OR TYPE your information and return this form and child(ren)'s forms with a
signed consent form and your payment.
Ethnicity (Optional) ___________________Occupation: _______________________ Employer:________________________
Do you have any reasonable accommodation needs we should be aware of? _____________________________________________
WORKSHOP FOR WHICH YOU ARE APPLYING: 1st Choice: DATE:________________CITY:_______________________
2nd Choice: DATE:________________CITY:_______________________
How were you referred to KIDS' TURN? (Circle one all that apply)
Judge
Attorney
Mediator
Therapist
Family Court Services
School
Friend
Family
Other ____________________
Is your family court ordered to attend Kids' Turn? Yes_______ No________
Have you attended Kids' Turn before? (If yes, when?) Approximate Month________ Year _______
ENROLLED CHILDREN MUST ATTEND ALL SIX SESSIONS WITH THEIR ENROLLED PARENT(S).
How many years did you and your child(ren)’s other parent live together?_________________________________________
What is the approximate date you and your child’s other parent stopped living together? Month___________Year________
[Families cannot attend Kids’ Turn before separation takes place.]
Is there currently any litigation concerning child custody or visitation? _________Yes ________No
If yes, please explain:
Has your family been involved with Child Protective Services? _________Yes ________No
If yes, please explain:
Restraining Order (R.O. or T.R.O).? _____Current _____Past _____None (If you checked “current” or “past” please provide
KidsTurn with the R.O. or T.R.O. documents).
[Parents with a current restraining order should attend separate workshops, unless the restraining order allows for peaceful contact for the purpose
of dealing with custodial arrangement, or unless the restraining order can safely be altered to permit attendance at Kids' Turn.]
Is there or has there been domestic violence in your home? _______ yes _______ no
If yes, please explain:
How have you been affected by this separation or divorce?
What do you hope to get out of attending the parent's workshop?
Does your child's other parent have information about the workshop? ________Yes ________No
Last printed 2/20/2006 5:52:00 PM
Parent ID #___________
Identifying Information
Parent Registration, Kid’s registration form(s), 10-17 teen form
Last name: _______________
First name_________________
Address: ____________________________________
(street)
________________________________________
(city)
(zip)
Home phone: ___________________
Alternate Phone: ____________________
Other Parent information: (Does NOT mean he/she is registered)
Name:
_________________________________________________
(first)
(Last)
Address: _________________________________________________
Street)
___________________________________________________________________
(city)
(zip)
Children Information:
Child(ren)’s Name(s): _____________________ __________________
(first)
(last)
DOB:________
_____________________________
________________________
DOB:________
_____________________________
________________________
DOB:________
_____________________________
________________________
DOB:________
Teen Information if child(ren) are between 10-17 years old:
Teen’s Name(s): _____________________ ____________________
(first)
____________________________
(first)
DOB:________
(Last)
___________________________
(Last)
DOB:________
Last printed 10/11/2006 2:45:00 PM
Parent ID _____________
PARENT’S QUESTIONNAIRE
Date: __________________
Parent Initials: _____________________
Please assist us in understanding more about your family’s situation. We will later pair
this information with an evaluation form to understand what you have gained from
attending Kids' Turn. This information will remain confidential.
1. I have a good understanding of my child(ren)’s reactions to the separation/divorce.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
2. I have open and effective communication with my child.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
3. My child talks to me about his/her feelings, questions, and concerns regarding the
separation/divorce.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
4. I generally know how to respond when my child asks me difficult questions about the
divorce or expresses his/her feelings about the divorce.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
5. Communication with my child’s other parent is difficult.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Please complete and return this form to the Kids' Turn office with your registration
forms: 1242 Market Street, 2nd Floor, San Francisco, CA 94102
Last printed 10/11/2006 2:46:00 PMAM