Registration Form

Please supply the requested information as thoroughly as possible by the registration deadlines. Your information will be treated as confidential and will not be shared with any third parties.

I would like to register for the following educational opportunity / support group:

To see our current course / group offerings, click here

Note: In many of our classes and groups, the subject of forgiveness arises. If you are interested in this topic, please indicate your specific interest below.
 
I am interested in learning about strategies for forgiving the following: (Check all that apply)
Abuse
Betrayal
Childhood Hurts
Infidelity
Myself
Other - Briefly Describe

YOUR PERSONAL INFORMATION

LAST NAME:
FIRST NAME:
SUFFIX:
GENDER:
RACE:
AGE:
YEAR BORN:

ADDITIONAL PERSON'S INFORMATION

LAST NAME:
FIRST NAME:
SUFFIX:
GENDER:
RACE:
AGE:
YEAR BORN:
RELATIONSHIP TO YOU: Spouse
Significant other
Friend
Other - Briefly Describe

MAILING ADDRESS

STREET:
CITY:
STATE:
ZIP:

CONTACT INFORMATION

Your phone number(s):
Additional person's number(s):
Your email address:
Additional person's email address:
What are the best day and time to reach you?
If we call and you don't answer, may we leave a message on your voicemail? Yes
No
If we call and you don't answer, may we leave a message with someone who answers? Yes
No

FAMILY STATUS

What is your current marital status? Married    Single
Do you have children under 18? Yes    No
If so, how many?

RELIGIOUS STATUS

Religious Affiliation/Denomination:
Do you have a leadership role in your religious institution? Yes
No
If yes, briefly describe your leadership role.

OCCUPATIONAL & EDUCATIONAL STATUS

OCCUPATION:
If employed, what is your workload? Full-time    Part-time
HIGHEST DEGREE EARNED:
Are you currently enrolled in an educational or certificate program? Yes    No
If yes, briefly describe what you are studying.

AFFILIATIONS

Are you a former MTSAC student of Dr. Stewart Thomas? Yes
No
If yes, what class(es) did you take? (Check all that apply)
Introduction to Sociology
Marriage & the Family
Child Development
Race & Ethnicity
What year were you in her class?
Are you a USC Passing the Mantle Alumnus? Yes
No

SPECIAL ACCOMMODATIONS

Do you have any physical challenges that require special accommodations? Yes
No
If yes, briefly describe how we might accommodate you.

FINAL QUESTIONS

How did you hear about this seminar, class, or support group?
What inspired you to register for this seminar, class, or support group?
What else would you like for us to know?

Thank you for completing this registration form!
Someone will be in touch with you soon.

Contact Us

The Relationship Repair and Care Clinic
969 S. Village Oaks Drive
Suite 104
Covina, CA 91724
626-622-2502
Info@RepairAndCare.org

Schedule of Classes / Groups

Register Here

Interest Form

Psychology Today


Counter: