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Individual Forms

Level II: Families in Transition Form (with Fee Waiver)

FAMILIES IN TRANSITION LEVEL II CLASS REGISTRATION WITH REDUCED FEE APPLICATION

About You
First Name *
Last Name *
First Name
Last Name
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
I agree to accept texts at this number:
About Your Case
Is your case filed in court?:
Have you been court ordered to participate in the parenting class?:

Parents are not allowed to take the class together when participation is court ordered.

About the Other Parent
First Name *
Last Name *
First Name
Last Name
About the Child/Children
Click all age ranges that apply:
Class Options
Choose one:

If you select Zoom livestream, remember, you must be able to have your camera on and have microphone access to the entire 2 hours to receive credit for the course.

Application for Reduced Fees

Mediation West offers a sliding fee scale based on your household size and income. You will need to provide income verification for each adult counted in your household size to pass audit requirements.

Income verification must be provided for each adult used to figure household size. Please indicate which item(s) you will be uploading.

With my electronic signature, I certify that as of today’s date, my gross household income and the number of people living in my household are as I have indicated above. I understand that this information will be used in determining my eligibility for participation in the reduced fee grant program which utilizes federal and state funds; falsification of claims made on this application may subject the reporting party to federal or state penalties.

First Name *
Last Name *
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$29.87
Credit Card Information
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Your total payment will be
Your credit balance will cover
Your credit card will be charged
Your bank account will be charged
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