Parenting the New Children
Class Registration Form

Registrant Name:

Date of Birth:

Function: father, mother, co-parent, step-father, step-mother

Address:

Phone (best phone number to reach you in case of cancellation):

Email address:

Second Registrant Name:

Date of Birth:

Function: father, mother, co-parent, step-father, step-mother

Address:

Phone (best phone number to reach you in case of cancellation):

Email address:

Name and date of birth of child:

Do you consider one or more than one of your children to be Indigos? Yes/No

To better serve the needs of the class, please briefly describe your child and what they are currently experiencing:

The cost for these classes is: $200.00 for the first parent, $100 for the second parent.

Payment must be made in full and by the first class.

Payment may be made by check, cash, or through PayPal, which you may access through our site.

This information may be printed and sent to Mica or emailed .

Mica M. Renes, N.D.
106 Wellington Place,
Cincinnati, OH 45219
Phone (513) 665-9015
Email: mica@micarenes.com