Child Impact Seminar Registration Form
If you need assistance registering, please call 603-434-1577
The entire Child Impact Seminar lasts for 4 hours. A Certificate of Attendance will be issued after completion of the 4 hour requirement, provided we have your required court docket number. Wednesday evening seminars are presented in 2 hour sessions from 6-8 PM on consecutive Wednesdays. Saturday seminars run from 9 AM - 1 PM.
Classes will be held in our Derry office @ 10 Tsienneto Rd., Derry, NH
and will start promptly at the scheduled time.
LATE ADMITTANCE WILL NOT BE ALLOWED.

The fee for the entire seminar is $85.00 per person.

Please be sure to complete all mandatory fields in the Class Registration form below before clicking the "Submit My Info" button. You will then be directed to PayPal to complete payment in full for the $85.00 registration fee using a credit or debit card.

If you are receiving state aid (food stamps, APTD, TANF, or Healthy Kids Gold) then you may qualify for a reduced fee. Please print the PDF form for Hardship Fee Reduction listed below. Complete and return to CLM for approval before you can register for the Child Impact Seminar. Mail or deliver this form to Center for Life Management, 10 Tsienneto Road, Derry, NH 03038, Attn: Child Impact Coordinator.

If you are not receiving assistance, but are unable to pay, you may request a reduced or waived fee. You MUST first download and complete the Hardship Fee Reduction form and a NH Court Motion to Waive/Reduce Fee below and submit it to CLM for approval before you can register for the Child Impact Seminar.

If you have any questions about these forms, please call 603-434-1577.

PDF Files require the FREE Adobe Acrobat Reader... get it here...

Items with an asterisk (*) must be completed!
Case Details
Are You In Mediation?*YesNo
Court Name*
Personal Information
All Personal data must be consistent with the Court Records...
Court Docket or Case Number*
First Name*
Middle Name or Initial
Last Name*
Maiden Name (if applicable)
This must be your Mailing address...
Street Address*
Street Address 2
City*
State*
Zip*
Primary
Phone
*
check if OK to leave a message
Secondary
Phone
check if OK to leave a message
eMail*check if OK to eMail
Co-Parent's First Name*
Co-Parent's Middle Name or Initial
Co-Parent's Last Name*
Session Information
Is there a Restraining Order in effect in this case?*YesNo
Do you wish to be enrolled in a separate class from co-parent?*YesNo
Session Date and Time Desired. Please indicate choices...

*Please note that your placement in a particular seminar is not guaranteed until it is confirmed by this office.
1st Choice*
2nd Choice*
3rd Choice*
After submitting your information, please read the new "Additional Information" at the top of the form and then proceed to PayPal to make your $85.00 payment...