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Parenting Class Registration

1. Provide Us With Your Information

First Name Last Name 
Street Address Unit No.
City Zip Code 
Phone Mobile PhoneeMail
Relationship
How did you hear about us?



2. Caregiver Information (if different, than above)

First NameLast Name
Street AddressUnit No.
CityZip Code
Home PhoneMobile Phone
eMail

3. Preferred Class Date

 DateCityFacilityLocationInstructor
1/17/2012 5:30:00 PMLakelandFamily Fundamentals1021 Lakeland Hills BlvdMarie Maddox
1/23/2012 6:00:00 PMLakelandKids' Town Preschool333 Griffin AvenueMelanie Walkington
1/24/2012 5:30:00 PMWinter HavenPolk County NE Government Center3425 Lake Alfred RoadConnie Forgues
4/16/2012 6:00:00 PMWinter HavenEloise Resource Center710 Snively AvenueMelanie Walkington
4/17/2012 5:30:00 PMLakelandFamily Fundamentals1021 Lakeland Hills BlvdMarie Maddox
5/15/2012 5:30:00 PMWinter HavenPolk County NE Government Center3425 Lake Alfred RoadConnie Forgues
8/7/2012 5:30:00 PMLakelandFamily Fundamentals1021 Lakeland Hills BlvdMarie Maddox
9/10/2012 6:00:00 PMFort MeadeHELP of Ft. Meade (Gause)1002 NE 6th StreetMelanie Walkington
9/18/2012 5:30:00 PMWinter HavenPolk County NE Government Center3425 Lake Alfred RoadConnie Forgues

4. Fee Acknowledgement




5. Child Information

Please provide us with the age and gender of each child in your care










If all information above is correct, submit registration here



Having Problems?

If you are having problems completing this form or have other questions, please contact us at 863.534.xxxx




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We enhance the quality of life for people throughout Polk County
Polk County Board of County Commissioners | 330 West Church Street | P.O. Box 9005 | Bartow, FL 33830 | 863.534.6000