Teen Peer Support Group Registration Form

Teen Peer Support Group Registration Form
Thank you for your interest in our Teen Peer Support Group. This support group will be held virtually, once a month. The group is offered to teen girls, from ages 14 to 18. Join us as we discuss topics such as: How to Have Difficult Conversations, Courage, and Confidence, Creating Life Balance, Dealing with Life Pressures, Embracing Self, and Boundaries, and Limits.

Slots are first come first serve. Registrations is from March 15th to April 15th, Once all spaces have been filled the group will be closed until the Fall. If you have any questions prior to registering, please feel free to reach out to connect@harminiccc.com.

Please note: A link to the meeting will be sent out by April 17th to all registered participants.
Teen's Name

First NameLast Name
Teen's Email
example@example.com
Teen's Phone Number

Area CodePhone Number
Guardian's Name

First NameLast Name
Guardian's Email
example@example.com
Guardian's Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Registration

MonthDayYear
Date
Teen's Date of Birth

MonthDayYear
Date
Meeting Dates
- April 25th-5:00 PM to 6:15 PM
- May 30th-5:00 PM to 6:15 PM
- June 27th-2:00 PM to 3:15 PM
- July 25th-2:00 PM to 3:15 PM
- Fall dates will be released in June.

My Products

Full Payment$160.00

This is a full payment. With this option, you will not have any payments remaining.

Half Payment$80.00

This is a half portion of your full payment. The remaining amount, $80, will be charged on 4/18/2023.