Coping with School Anxiety Registration

Coping with School Anxiety

A six-session workshop for teens
Wednesdays, beginning September 18 thru October 23
from 5:00 - 6:00 p.m.

Cost: $180
Sorry, no refunds for missed sessions.
Name of Teen*

First NameLast Name
Age Grade *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent or Guardian*

First NameLast Name
Does the teen live with you: Yes No. If no, name of custodial parent:First and Last Name.
Your Phone Number*
Phone number of Teen
Your email*
example@example.com
I prefer to be contacted via:*

PhoneText message - by providing a cell phone number and checking this box, you are consenting to contact by SMS text messaging. Message and data rates may apply. You can reply STOP to opt-out of further messaging at any time.Email
How did you hear about the workshop?

Friend or colleagueSearch EnginePastorRelativeCDPCC websiteTherapistOther
Payment
Payment Due*

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Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Coping with School Anxiety