RPC reg form – Strengthening Families, Strengthening Communities

Initials *

Postcode *

Date of birth *

Have you taken a parent education course or received relationship support in the last 12 months? *

What is your first language? *

By this we mean the first language you learnt, or the language that you grew up speaking.

Ages of children

Tell us the ages of each of your children (this includes step children)

What is your current parenting status or relationship to the child? *

If other, please describe.

What is your ethnic group? *

If other, please describe.

How do you personally define your gender *

Please tell us in your own words below if none of the categories above are right for you.

If other, please describe.

Is your gender identity the same as the one assigned to you at birth? *

Which of the following best describes your sexual orientation? *

Faith / Religion / Belief *

If other, please describe.

What is your household income level (per year) *

Schooling completed *

Please select the highest level that you completed

Why are you taking this course? *

If other, please describe.

How did you hear about this course? *

If other, please describe.

Name of referral agency