Registration for Smart Steps to Healthy Fatherhood

If you have additional questions, please email: rachel.ross@familysupportcenter.org, or call Shelli Mecham at 801-955-9110 x116

Date
Date
Name of Adult *
Name of Adult
Birthdate
Birthdate
Address
Address
Phone
Phone
Name of Adult
Name of Adult
Birthdate
Birthdate
Address
Address
Only if Different from Above
Phone
Phone
Family Structure
Marital Status
Information Regarding Children who will be attending ONLY
Child 1
Child 1 Name
Child 1 Name
Please be aware that we are not able to accommodate all special dietary needs. We will do our best. You are welcome to bring food to enjoy with the group or eat before coming.
Child 2
Child 2 Name
Child 2 Name
Please be aware that we are not able to accommodate all special dietary needs. We will do our best. You are welcome to bring food to enjoy with the group or eat before coming.
Child 3
Child 3 Name
Child 3 Name
Please be aware that we are not able to accommodate all special dietary needs. We will do our best. You are welcome to bring food to enjoy with the group or eat before coming.
Child 4
Child 4 Name
Child 4 Name
Please be aware that we are not able to accommodate all special dietary needs. We will do our best. You are welcome to bring food to enjoy with the group or eat before coming.
Child 5
Child 5 Name
Child 5 Name
Please be aware that we are not able to accommodate all special dietary needs. We will do our best. You are welcome to bring food to enjoy with the group or eat before coming.
Child 6
Child 6 Name
Child 6 Name
Please be aware that we are not able to accommodate all special dietary needs. We will do our best. You are welcome to bring food to enjoy with the group or eat before coming.
Emergency Contact
Emergency Contact Name
Emergency Contact Name
Address
Address
Home Phone
Home Phone
Work Phone
Work Phone
Alternate Number
Alternate Number