Child Impact Seminar Registration

Child Impact Program Registration Form

If you need assistance in registering, please call 603-965-0601

Program Information

The Child Impact Program is a 4-hour requirement.
Offered on:
- 2 consecutive Wednesday evenings in 2-hour sessions 6-8pm
- Saturdays in one 4-hour session 9-1pm
Please refer to the schedule for Program dates and times on the Child Impact Registration Form
To receive a Certificate of Attendance you must complete the 4 hour requirement and provide your required court docket number.
Programs will be held in our Derry office: 10 Tsienneto Rd., Derry, NH
Programs start promptly on scheduled time
LATE ADMITTANCE WILL NOT BE ALLOWED.

PDF Files require the FREE Adobe Acrobat Reader... get it here...

Registration Fee:

The fee for the Program is $85.00 per person
Please Note: The fee must be paid, via PayPal, by credit/debit card, or by check or Money Order when registering for the Program or you will not be placed in a class.

State Aid:

If you are receiving state aid (food stamps, APTD, TANF, or Medicaid/Medicare) then you may qualify for a reduced fee.
Please download and complete the PDF form CIP Request to Reduce or Waive Fee listed below.
Return to CLM with proof of state assistance for approval before you can register for the Child Impact Program.
Mail or deliver this form to Center for Life Management, 10 Tsienneto Road, Derry, NH 03038, Attn: Child Impact Coordinator.

Requesting a Reduced or Waived Fee:

If you are not receiving assistance, but are unable to pay, you may request a reduced or waived fee.
You must download and complete the CIP Request to Reduce or Waive Fee and the State of NH Financial Affidavit forms. The NH Financial Affidavit must be notarized by the court.
Return to CLM for approval before you can register for the Child Impact Program.
Mail or deliver this form to Center for Life Management, 10 Tsienneto Road, Derry, NH 03038, Attn: Child Impact Coordinator.

PDF Files require the FREE Adobe Acrobat Reader... get it here...

Confirmation

Rescheduling Fee

A Rescheduling fee of $25.00 will be charged for any cancellations received within 48 hours before the scheduled Program or for any missed sessions. The rescheduling fee must be paid before the rescheduled class.

Forfeiture of Registration Fee

Failure to complete the program within 6 months of registration will result in forfeiture of registration fee.

If you have questions about completing any of these forms, please call 603-965-0601

Items with an asterisk (*) must be completed!
Case Details
What is your reason for attending this Program?*		Court Order - Self Help
Court Docket or Case Number* (Enter "unknown" if information is unavailable!)
Court Name*

Personal Information
All Personal data must be consistent with the Court Records...
First Name*
Last Name*
Maiden Name (if applicable)
This must be your Mailing address...
Street Address*
Street Address 2
City*
State*
Zip*
Primary Phone*
Secondary Phone
eMail*
Co-Parent's First Name*
Co-Parent's Last Name*

Session Information
Is there a DVP or Restraining Order in effect in this case?*	Yes - No
Do you wish to be enrolled in a separate class from co-parent?*	Yes - No
Do you have/require any Special Needs to attend class? (Interpreter, sign language, etc...)
Session Date and Time Desired. Please indicate choices... *Please note that your placement in a particular seminar is NOT guaranteed until your $85.00 payment is received and it is confirmed by this office.	1st Choice*
	2nd Choice*
	3rd Choice*
After submitting your information, please read the new instructions at the top of the form!