Children & Teens Program
Select a date:
*
March 30, 2025: In-person from 10:30 - 5:00 at Caron's Wernersville Campus
April 7th and April 10th, 2025: Virtual YEP from 6:30-8:00
Child's Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
*
Grade
*
School District
*
Preferred Email for Group Invitation Links
*
example@gmail.com
Parent/ Guardian Information:
Name
*
First Name
Last Name
Email
*
example@example.com
Preferred Phone Number to reach you during program
*
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Child & Family Information:
Any concerns about your child or any other information about your child you want us to be aware of?
*
Is the child aware of family member’s substance use disorder?
*
Is the family member’s substance use in the past or current? Does the child live with this family member?
*
Is the child having any difficulties or problems at school?
*
How did you hear about our program?
*
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Child Health Information:
Does the child have any physical limitations?
*
Yes
No
If yes, please explain.
*
Does the child have any allergies or dietary restrictions?
*
Yes
No
Please describe the allergies or dietary restrictions.
*
Is the child taking any medications on a regular basis?
*
Yes
No
Please list all medications.
*
Please verify that you are human
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