Girl Talk Group Registration Form

Girl Talk Group Registration Form
Youth Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / 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 NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Relationship
Payment Details

Fee

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

Total

$0.00

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

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Date Signed

MonthDayYear
Date
Should be Empty:

Girl Talk Group Registration Form

Parent/Guardian Information

Payment Details

Acknowledgment