Battered Mothers Application

APPLICATION FOR MOTHER'S DISCOUNT RATE AHD/OR REFERRAL TO OTHER ATTENDEES FOR RIDES, ROOMS, ETC.

After you have been approved, you will receive an email with a link to register at the lower mother's rate.
You will also receive an invitation to our online Room and Ride Share Group. Thanks!

We require that all questions be answered to insure the safety of everyone attending the conference and in our online forum.. Your information is private and will not be sold or shared. When you have completed the questions below, please click on the submit button at the bottom only once. We will contact you when we receive your application. THANK YOU!

1. Last Name

2. First Name and Middle Initial

3. Full home Address, including City and State

4. Email

5. Phone

6. Name and relationship of opposing party

7. Your case name and number; your attorney's name

8. Date your case was filed

9. How many years have you been in active litigation?

10. Location of your case (county)

11. Location of your case (state)

12. Outcome of your case

13. (*Answer only if you are applying for a fee reduction:): Approximately how much has the litigation cost you?

14. (*Answer only if you are applying for a fee reduction:): Are you employed? What is your income per year?

15. (*Answer only if you are applying for a fee reduction:)::Do you pay child support?

16. What, if any, groups, organizations, etc. are you affiliated with , activist, legal reform, or otherwise?

16. Please write a very brief summary of what happened to you and why you are asking to be connected with other attendees and/or for the discount rate.
Please include the name of a DV advocate or organization who you have worked with.

THANK YOU!