Girl Talk Group Registration Form
Youth Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
Grade Level
Has your child been diagnosed with a Mental Health Diagnosis, If so please identify?
Parent/Guardian Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Relationship
Payment Details
Fee
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Fee per Group
Invoice will be emailed when form is completed. Payments will be made via WaveApps. Child will not be able to participate in groups if payment has not been made. Payments may be made upfront or weekly.
$
15.00
10 weeks in full
$
150.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Acknowledgment
I agree to follow the guidelines, rules, and policies of the organization.
Parent/Guardian registered in this form has legal custody over the child.
Cancellations will be subject to a full charge if
NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE.
If you are late for a group, you may lose some of that session time. There is a 10-minute grace period. If you do not arrive for your session within that time, you will be charged a no-show fee and your appointment will be canceled.
I agree to pay for groups prior to the start of each group and understand that my child will not be able to participate if payment has not been made. Payments will be made via WaveApps. A card will be kept on file. Please ensure that this card is valid.
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
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