Enroll

Enroll and pay online, or download the enrollment and scholarship forms.

Confidential Enrollment Form

Name *

Address *

Country

City

State

Zip code

Home Phone

Cell Phone

Work Phone

Email *

Fax

Preferred Method of Receiving Information *

US Postal Mail

Fax

Name of Child(ren)'s Other Parent *

Class size is limited. Parents are enrolled in order that application is received. You cannot be placed in the same class as your child(ren)’s other parent.

Class Selection Request

Please indicate your first and second choices below for class selection. Available sessions can be found at http://actforchildren-rochester.org/schedule/.

Separating parents cannot participate in the same session and registrations will be processed in the order they are received. Following this registration request you will receive a confirmation email or letter confirming which date you have been placed in. That letter will also include the class location. You are not enrolled until you receive this confirmation.

Class Selection - First Choice *

Please enter the session you prefer to attend.

Class Selection - Second Choice *

Please enter an alternate session request in the event you cannot be placed in your first choice.

Are you currently in danger? *

Are you currently in danger of your partner or ex-partner doing any of the following: (1) Physically hurting you by, for example, pushing, grabbing, slapping, hitting, choking or kicking? OR (2) Threatening to hurt you, your children or someone close to you? OR (3) Stalking, checking up on you or following you? OR (4) Making you afraid?

Yes - you will be contacted by the program administrator. Please indicate the safest way to contact you below.

No - None of the above applies to me or I choose not to answer these questions at this time.

If you answered yes to the question above, please list the safest way to contact you.

Is your case currently in court?

If your case is currently in court, please complete the information below.

Judge's Name

Family Court File Number

Supreme Court Index Number

Payment Instructions

Class registration is $100. When you click submit below, you will be directed to a Square payment checkout page.

Date

View Schedule

Download Form

Enrollment: If you prefer not to enroll online, you can download and mail in the form. Click here to download the enrollment form.