DHP: Triple P Registration Form FY 25-26

Step 2: Enter the member's information as seen on the Driscoll Health Plan card

To make sure you are registered for one of our classes, please review the information below as seen on your member identification card.
Member's Name*

First NameLast Name
Member's Date of Birth*

MonthDayYear
Today's Date

MonthDayYear
Date
Member's Age*
Are you currently pregnant?

YesNo
We're sorry, but Triple P sessions are only for Legal Guardians of children ages 0–12 or teens ages 13–20. If you have any questions, please call Member Services at 1-877-324-7543.

Step 3: Enter the Mailing Information

Legal Authorized Representative who completes a Triple P Class will receive a $20 gift card. *Restrictions and limitations may apply.

To make sure you receive a gift card after completing the class and survey, please review and update the information below.
Legal Authorized Representative's Name*

First NameLast Name
Mailing Address*
Street Address
City*
City
State*
State
Zip Code*
Zip Code
Phone Number*
Please enter a valid phone number.
Email

Confirmation Emailexample@example.com
May we text or email class information to you?*

TextEmail
Be sure to check your emails for the class schedule reminder.

Step 4: Please select the date and time of your Triple P Class