Psychotherapy Associates
of North Reading

Parent Class Registration

Name:_____________________________ Today's Date:_________________

Address:______________________________________________________________

_____________________________________________________________________

Home Phone:___________________ Work Phone:____________________

Date of class you wish to attend:_________________________________

Location of class (please circle one):

Little School	Medford High School	Northern Essex Community College
North Reading	Medford	Haverhill

We need the name of your spouse so we can make sure you are not both taking the same class.

Spouse's name:_____________________________________________

All classes take place on two consecutive nights from 6:30 to 9:00 both nights. You must attend a separate class from your spouse, and your space in the class is reserved once we receive the $80.00 payment. Please note that child care is not provided, and children are not permitted to attend the classes.

Please mail this form along with a check or money order for $80.00 payable to PANR. (Do not mail cash.) Once we receive payment, we will mail a confirmation letter along with directions to the class you are attending.

Please mail to: