RegisterForProgram :: Gentle Warriors Academy (powered by Entrepid™)

First Name *

Last Name *

Your Email *

Phone *

Referred by *

Date of birth *

Age *

Gender *

Marital Status *

Home Address: Line 1 *

Home Address: Line 2

Cell Phone *

City *

State *

County *

Zip Code *

2nd Phone number (alternate)

Ethnicity *

Are you a father? *

Do you have a child 16 years of age or younger? *

# of children *

Employment Status *

Length of Employment *

Have you ever been in a fatherhood program? *

Associated Organization, may choose more that one *

How did you hear about us? *

Need help with: *

Pick one

Preferred method of contact *

Are you currently on probation or parole? *

Were you released from incarceration within the last 9 months?

Are you aware of the policy of LEGITIMATION? *

Do you need support in processing a legitimation case? *

How many of your children are in need of legitimation actions? *

What are their ages? *

Have you successfully completed a legitimation case? *

Do you have a child support order? *

Are you currently in child support arrears? *

# of children under 23 living in your residence

# of children under 23 living outside of your home

Preferred Name/Nickname

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