Child Impact Seminar Registration First Name * Middle Name Last Name * Email Address Street Address * Apt # City * State (ex. NH) * Zip Code Daytime Phone Number * Docket # or Case # * (This can be found on all your court documents) County and Family Division Please Provide Your Co-Parent's Name We require parents to attend separate classes – you may not attend the same class as your co-parent. Is a restraining order in effect in this case? * Yes No Payment Options * Mail your check or money order to Child Impact Program, Greater Nashua Mental Health Center, 15 Prospect Street, Nashua, NH 03060 PRIOR to the day of class payment can be made via cash, check, money order, or credit card at the above address Please Note CLASS LOCATION: 100 West Pearl Street, Nashua NH 03060 Your registration is not complete until payment has been received. Please check your preferred method of payment. Payments will NOT be accepted at class and must be made in full prior to your class date. If you are receiving state aid (food stamps, APTD, TANF, medicaid or Healthy Kids Gold) then you may qualify for a reduced fee. Please call Patricia Marshall at 889-6147, ext: 3210 Seminar Preference * Saturday, October 21, 2017 9am-1pm Saturday, November 4, 2017 9am-1pm Tuesday November 7 & 14 2017 6-8pm Saturday, December 2, 2017 9am-1pm Saturday, December 9, 2017 9am-1pm The seminar consists of a 4 hour session or two 2-hour sessions. You must attend the complete 4 hours of the session. Please indicate your preferred seminar date. If your preferred seminar is not available, you will be placed in the next open class. *Please note that your placement in a particular seminar is not guaranteed until it is confirmed by this office.