COS Registration

"MENDING AND LETTING GO, ONE CLASS AT A TIME"- PARTICIPANT

Registration:

I would like to register for the following dates. MUST attend all dates listed. *

February 17, 24 March 3, 10, 17, 24 at Fun and Fancy-Free Learning Center in Polson Add me to list for future classes.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Tribal Affiliation (If applicable, this program is open to all) *

Age *

How did you hear about Mending Broken Hearts? *

Do you have any special needs for learning in a classroom? If so, please indicate what your needs are. *

Do you have any dietary restrictions we should be aware of? * *

Do you need childcare? *

Yes No

PHOTO RELEASE: By selecting yes, you are granting permission to Families First to take photos and/or videos of you for the purpose of publication, promotion, and/or advertising. * *

Yes No

If yes, include how many children and their ages. *

Submit