Parenting Education Program Registration

(* Denotes Required Fields)

PEP Registration Form
Please enter your full legal name as it matches court records.
First Name: *
Last Name: *
Date of Birth (month/day/year: 11/12/1991): *
Cell phone: *
Street Address: *
City/Town: *
State: *
Zip code: *
Gender: *	Female Male Non-Binary/Third Gender
Home Phone:
Do you need an interpretor?: *	Yes No
If yes, what is your primary language?:
Please select the Court Location of your case: *	Ansonia/Milford Bridegeport Danbury Hartford Meriden Middlesex New Britain New Haven New London Norwich Stamford Tolland Torrington Waterbury Windham
Docket number: *
Other party in your court case (full name found on court documents).: *
Protective Order pending or in effect with your other party?: *	Yes No
Restraining Order pending or in effect with the other party in your case?: *	Yes No
Please indicate the number of children included as a result of your case? : *	1 Child 2 Children 3 Children 4 Children 5 Children 6 Children 7 Children 8 Children
Please indicate the age(s) of the child(ren) affected by this case. If more than one child, please separate age by comma. For example, 5, 8, 14: