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Child Impact Registration Page
cpweb18admin333
2023-10-18T10:54:21-04:00
Child Impact Program Class Registration
PLEASE NOTE that all Child Impact Program classes will be held via live video conference only, and will require participants to access Zoom via a device with audio and video capability. Please indicate which Child Impact Program class you are registering for:
Saturday, 5 October 2024, 9am - 1pm
Saturday, 19 October 2024, 9am - 1pm
Saturday, 2 November 2024, 9am - 1pm
Saturday, 16 November 2024, 9am - 1pm
Saturday, 7 December 2024, 9am - 1pm
If the class you are registering for is full, we will contact you. May we automatically register you for the next available class that has a seat open?
Yes
No
Attendee Name
First Name
Middle Name or Initial
Last Name
Email
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
Cell Phone
Work Phone
Date of Birth
MM slash DD slash YYYY
Court Docket or Case Number (if filed):
Court Name/Location
Name of Co-Parent
First
Last
Is there a history of domestic violence or abuse in this relationship, or a restraining order filed in this case? (If yes, co-parents are not permitted to attend the same CIP class.)
Yes
No
Are you comfortable attending the CIP class with co-parent? (Note: co-parent attendance in the same class is at the discretion of the program provider.)
Yes
No
Do you need a foreign language interpreter?
Yes
No
Do you need a sign language interpreter?
Yes
No
Are you seeking a CIP class fee reduction to $50 on the basis of need? You will be required to submit a photocopy of your NH EBT (Food Stamps Program) and/or Medicaid card to qualify.
Yes
No
Are you seeking to have the CIP class fee waived entirely on the basis of need (low/no income)? You will be required to submit a State of NH Financial Affidavit (see link below).
Yes
No
CLICK HERE to open the official State of NH Financial Affidavit form in a new browser tab
If you need to submit an electronic copy of your State of NH Financial Affidavit, or a scanned photocopy of your NH EBT or Medicaid card (or any other pertinent documentation) with your CIP class registration, click on the 'Select Files' button below, then navigate to your file(s) and attach here.
Drop files here or
Select files
Max. file size: 80 MB.
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