HOPE Registrations Fall Session 2018
Summer Session: September 24, October 8 and 22, and November 5, 2018

Fees: $100 per person
Location: Community Mediation Center
Kaufman House
Bethel College
2515 College Avenue PO Box 276
North Newton, KS 67117

1. Full Name *
Your answer
2. Birth Date *
Your answer
3. Gender *
4. Street Address *
Your answer
5. City/State *
Your answer
6. Zip Code *
Your answer
7. Email *
Your answer
8a. Cell Phone *
Your answer
8b. Home Phone *
Your answer
8c. Work Phone
Your answer
9. Name of Your Attorney *
Your answer
10. Name of Your Case Manager Appointed by the Court, if any. If none, write N/A. *
Your answer
11. Name of Your Parent Coordinator Appointed by the Court, if any. If none, write N/A. *
Your answer
12. Employer *
Your answer
13. Are you under a court or other order to attend the HOPE class? If so, bring a copy of the order with you to the first class, or fax (316-284-5379) or email (dlengel@bethelks.edu) the order to us before the class begins. Check the appropriate box below. Note that without the order, we will not be able to notify the ordering entity of your participation, and they may declare you to be in non-compliance
Children
14. Children's Information *
Please list the names, genders, ages, and birthdates for all children.
Your answer
15. Full Name of Other Parent of Your Children *
Your answer
16. Date of divorce or separation *
Your answer
17. How long were you together? *
Your answer
18. Approximately how many times do you think you've been to Court for parenting matters including child support, custody, parenting time, etc.? *
Your answer
19. Have you taken part in mediation? What was the outcome of mediation? *
Your answer
20. Have you participated in case management? If so, for how long? *
Your answer
21. Have you participated in parent coordination? If so, for how long? *
Your answer
22. Which term best describes your overall relationship with your child's other parent? *
Extremely Hostile
Very Friendly
23. Please rate your ability to co-parent effectively. *
Very Poor
Excellent
Domestic Violence Screening Questions
24. For the HOPE classes, you and your child's other parent (if participating in the same HOPE session) will be in the same large classroom part of the time, but you will be seated separately and placed in separate groups for the main discussions. You will NOT be left alone with your child's other parent at any time. Please rate how comfortable you are with this arrangement. *
Very Uncomfortable
At Ease
25a. Are you afraid of your child's other parent for any reason? *
25b. If you answered "yes" to the question above, please explain. If you answered "no", write N/A. *
Your answer
26a. Has your child's other parent ever hit you or used any other kind of physical force against you? *
26b. If you answered "yes" to the question above, please explain. If you answered "no", write N/A. *
Your answer
27a. Has your child's other parent ever hit or used any kind of physical force against your child(ren)? *
27b. If you answered"yes" to the question above, please explain. If you answered "no", write N/A. *
Your answer
28a. Has your child's other parent ever threatened to hurt you or your child(ren) physically in any way? *
28b. If you answered "yes" to the question above, please explain. If you answered "no", write N/A. *
Your answer
29a. Are there any existing protection or restraint orders in place against either of you? *
29b. If you answered "yes" to the question above, please explain. If you answered "no", write N/A. *
Your answer
30a. Are you currently afraid that your child's other parent will physically harm you or your child(ren)? *
30b. If you answered "yes" to the question above, please explain. If you answered "no", write N/A. *
Your answer
31a. Is your chid's other parent verbally or emotionally abusive to you or your child(ren)? *
31b. If you answered "yes" to the question above, please explain. If you answered "no", write N/A. *
Your answer
32. Is there anything else that you would like to add at this time?
Your answer
Payment
The registration deadline is September 17, 2018 The fee for participation in this Session of HOPE classes is $100 per person. Payment in full must be received by September 17, 2018, unless special arrangements have been made with the HOPE facilitators IN WRITING by September 17, 2018. Classes are not prorated. No refunds will be made after the registration deadline.
Form of Payment *
Acknowledgement
I acknowledge I have read and accepted these terms of participation and payment. *
Submit
Never submit passwords through Google Forms.
This form was created inside of Bethel College.