Group Sign-Up Form

Group Sign-Up Form
Name of person that will be attending the group*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parent/Guardian Name if Applicable
Contact Email Address*
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Which group are you interested in joining?*
Which group are you interested in joining?*
Not all groups are currently active. If you request a group that is not active we will notify you when it starts
Which day and time works best for you?

Tuesdays at 11:30 amWednesdays at 6:30 pmNo Preference
What insurance do you have?
if none, enter N/A
Type of Insurance*
Insurance ID Number
Currently a client at Improving Lives Counseling Services?*

YesNo
Should be Empty: