Virtual Seminar Request Form - The Center for Parent Youth Understanding

Thank you for your interest in CPYU’s Virtual Parent Seminars. Please fill out the form below to begin the process of securing a possible date for your virtual event. After receiving your completed form, we will contact you regarding availability for your requested dates. Thanks for your interest in CPYU!

Sponsoring Organization Information
Church/Organization Name:*
Contact Name:*
First Last
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:*
Alternate Phone:
Email*
Event Information
Which Virtual Parent Seminar Are You Interested In?*
- Understanding and Addressing Anxiety in Your Kids (by Walt Mueller)
- Cultural Forces Shaping Children and Teens Today (by Walt Mueller)
- On-Purpose Parenting Through Uncertain Times (by Walt Mueller)
- Tech-Smart Parenting: How to Help Kids Flourish in a World of Smartphones and Social Media (by Walt Mueller)
Preferred Date #1:*
MM slash DD slash YYYY
Time of Day for Preferred Date #1*

: Hours

Minutes

AM/PM
Preferred Date #2:
MM slash DD slash YYYY
Time of Day for Preferred Date #2

: Hours

Minutes

AM/PM
Preferred Date #3:
MM slash DD slash YYYY
Time of Day for Preferred Date #3

: Hours

Minutes

AM/PM
Optional Q & A*
Are you interested in extending the 1 hour presentation with 30 minutes of Q&A for an additional $100?
- Yes
- No
- Undecided
Name
This field is for validation purposes and should be left unchanged.

Sponsoring Organization Information

Event Information