Pathways Online Education Authorization

Pathways to Education

Online Class Authorization
This education program is for participants living in only the following counties: Placer, Sacramento, El Dorado, Yolo, Yuba and Sutter.
Your Name*

First Name Last Name
Cell Phone*
Gender*
E-mail*
example@example.com
Your Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Your primary language*
Have you ever visited Sierra Pregnancy + Health before?*

YesNo
What was the name you used when SPH provided services to you before? First NameLast Name.
What person or organization referred you to our program?*
Verification of Identity and Address
Upload Image of Photo ID*
Upload Image of Address Verification (rent receipt, utlility bill, etc.)*
Earning with the Other Parent

We love to see families learning together! We allow mothers and fathers to take classes separately and then combine their units for a faster incentive gain. We require a separate Pathways to Education Authorize Form (this form) to be completed by both parents.
Do you want to combine your units with your baby/child's mother or father?

YesNo
What is your relationship to your child(ren)?

MotherFather
Name of the other Parent

First Name Last Name
In the case you want to discontinue earning together, you must text or email the Training + Education Manager a request to terminate the agreement. Please give 2 business days for a confirmation.
I give authorization that my contact information can be shared as set forth on this form to the Training + Education Manager of Sierra Pregnancy + Health (SPH).

I understand that:

1.     I have the right to revoke this authorization at any time in writing to SPH except to the extent that action has already been taken to contact and enroll me based on this authorization.

2.     Signing this authorization to contact and enroll is voluntary.

3.     The Training + Education Manager is not a licensed therapist, counselor, or certified teacher and cannot serve in the completion of required therapy, counseling, or court-ordered parenting classes.

4.     I am giving Sierra Pregnancy and Health permission to contact me through the contact phone via call or text and through the email provided.

5. This is an online program of over 200 videos ranging in topics designed to be done on my own personal device at home and I am responsible for earning my incentives by completing the full program requirements.

6. Sierra Pregnancy + Health can drop me from the enrolled program at their discretion and I will be dropped automatically if I am not participating regularly by completing a minimum of 5 classes per week.

7. If I have authorized to earn units with the other parent and want to end the agreement, I must contact the Training + Education Manager to terminate the agreement.

8. I understand the units I earn expire within 6 months and after expiration cannot be used for incentives or any other benefit with Sierra Pregnancy + Health or other organizations.
All items on this form have been completed by me and the answers on this form are true and correct. I authorize Sierra Pregnancy and Health to text me at the cell phone number provided and/or to leave a voicemail as necessary.*

Clear
Should be Empty:

Pathways to Education

Verification of Identity and Address

Earning with the Other Parent