Fathers In Touch Registration Form
Welcome to our Fathers In Touch group. Please fill out our registration form. The information participants share in this form is for the records of Capital Youth Empowerment Program (CYEP) and will not be shared with outside service providers unless the participant authorizes consent.
Date *
MM
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DD
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YYYY
First and Last Name *
Your answer
Date of Birth *
Your answer
Address (Street, City and State) *
Your answer
Phone Number *
Your answer
Which class are you registering for? *
Ethnicity *
Marital Status *
Employment Status *
Referred By: *
Name of Referral (Social Worker, Probation, etc)
Your answer
Referral Phone Number
Your answer
How Did You Hear About Fathers In Touch? *
Transportation *
Emergency Contact (Name/Phone) *
Your answer
Submit
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