Registration Form

Families are matched together in groups based on: when their babies are due, what part of town they live in, whether they want an evening group or daytime group, and when a leader is available to facilitate a group. Typically, we will place you in a Group anytime from four weeks to four months after your baby is born. You will receive an email notifying you of placement and asking you to confirm that the Group will work for you. Upon confirmation, you will then receive an invoice for the group fee. In some rare instances, registration may not result in placement given these time constraints, but we do our best to find everyone a Group.

PEPS Member Application

First Name (Required)

Your first name

Last Name (Required)

Your last name

Username (Required)

Choose a username for your new account (this cannot be an email address). Login is only valid and accessible after you receive your detailed Welcome Message from the PEPS office in 5-10 days.

Password (Required)

Please choose a password

Confirm Password (Required)

Please re-type your password

Type of Group (Required)

Please select which type of PEPS Group you are interested in.

Number of Parents Attending (Required)

How many will be attending PEPS Group meetings?

Second Parent's Name

If there will be two parents attending meetings (i.e. you answered '2' above), enter the second parent's full name.

Baby's Last Name (Required)

Your baby's last name

Baby's Birth Date or Due Date (Required)

Enter either your baby's date of birth or the expected due date (mm/dd/yyyy)

Cell Phone

Your cellphone number, including area code

Work Phone

Your work telephone number, including area code

Land Line

Your home telephone number, if different than cellphone number, including area code.

Email Address (Required)

Your most regularly checked address. ALL communication from PEPS is via email - remember that if you will be on maternity leave, your personal email may be your best choice!

Street (Required)

Your street address

Street, cont.

Suite, Apt. etc

City (Required)

Your city

County (Required)

Your county

Zip (Required)

Select your zipcode from the dropdown list

How did you hear about PEPS? (Required)

Comments

Please use this space for personal comments.

Employer

Your employer

Spouse/Partner Employer

Your spouse/partner's employer