MD Program Virtual Parent Book Club

Date Date / MM / DD YYYY
Please complete a separate registration for each participant.

Participant Name Please complete a separate registration for each participant.

Participant Name First Last
Participant Address Participant Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email Address:
Are you a Paths for Families staff member, contractor, intern, or professional partner?

Are you a Paths for Families staff member, contractor, intern, or professional partner? No Yes
Permanency Pathway
Where was your adoption or C&G finalized? (Please indicate city and state)
Have you ever participated in any Paths for Families programs (adoption, counseling, support groups, training, family finding, etc.)?
How did you hear about the Virtual Parent Book Club?
Please describe any features of your family make up that may impact family dynamics (i.e.- significant age gaps, racial/cultural differences, varying abilities, living arrangements, etc.). Your response helps the facilitators plan appropriate/relevant discussions.
Do you need any ADA accommodations to allow you to fully participate in this group? Please provide details in the space below.

Do you need any ADA accommodations to allow you to fully participate in this group? Please provide details in the space below. No Yes
Is there anything else you would like us to know?