Name *

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Last Name

Pronouns *

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She, Her, Hers

He, Him, His

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Address *

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Address 2

City

State/Province

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Phone *

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Is there a restraining order, protective order, or any other reason you would prefer not to take the class with the co-parent? *

Yes

No

Other reason

Are you currently giving or receiving child support payments through DSHS? *

Yes

No

Are you a Military Veteran? *

No

Yes

Prefer not to say

Ethnicity *

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Latinx

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Race *

American Indian or Alaska Native

American Indian or Alaska Native and Black/African American

American Indian or Alaska Native and White

Asian

Asian and White

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Other multi-racial

White

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Electronic Signature

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First Name

Last Name