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Children's Program Pre-Registration

Group of laughing children

Thanks for your interest in the Children's Program. Once you complete this form, a Children's Program counselor will contact you by phone to complete your registration and answer any questions you may have.

An error occurred during form submission. Please wait a few minutes and re-submit the form.

Caregiver Contact Information

* Caregiver Name Enter the Caregiver Name

* Caregiver Phone Number Enter a caregiver phone number

* Caregiver Email Address Enter a caregiver email address

* Caregiver Mailing Address 500 Characters remaining Enter a caregiver mailing address

* Caregiver Relationship to Child Enter the caregiver/child relationship. Example: Mother, Father, Grandparent

* Alternate Emergency Contact Name Enter an emergency contact name

* Alternate Emergency Contact Telephone Enter an alternate emergency contact phone number

Child or Children Information

* Child 1 Name Enter a child's first and last name

* Child 1 Date of Birth Enter the child's date of birth in the format mm/dd/yyyy

* Child 1 Gender Enter the child's gender

Child 2 Name

Child 2 Date of Birth

Child 2 Gender

Child 3 Name

Child 3 Date of Birth

Child 3 Gender

Additional Children (name/birth date/gender) 300 Characters remaining

How did you first hear about the Children's Program?

* I learned about the Children's Program from:

Hazelden Betty Ford website

Hazelden Betty Ford staff

Other treatment facility

Medical/Mental Health professional

School professional

Court system organization

Family member or friend

Other

Select how you first heard about the Children's program.