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Emotional Synergy Registration Form
FREE Six-Week Program for Parents and their Youth (11-17). Please fill in the form below. Next series at Homestead Middle School. Every Wednesday. Aug 27-Oct 1.
Name of Child (Must be between the age of 11-17).
*
First Name
Last Name
Choose the current age of your adolescent attending with you.
*
Please Select
11
12
13
14
15
16
17
Other
Grade of Child as of August 2025
*
K-1, 2-3, 4-5
Name of Parent/Guardian
*
First Name
Last Name
Parent/Guardian Phone Number
*
Format: (000) 000-0000.
Phone Number of Additional Emergency Contact
*
Format: (000) 000-0000.
How many children will be attending this event with you? Please complete a separate registration form per child to include the accompanying adult. We recommend, if possible, one adult per child. However, a parent/guardian can attend with a maximum of 2 children.
*
1
2
Other (Please call 786-708-7508 for details or if you require special accommodations).
Email
example@example.com
Name of Additional Emergency Contact
First Name
Last Name
Relation to Child
How often do you and your adolescent do fun activities together?
*
More than 5 times a week
2-4 times a week
1 time weekly
Other
Which of these describe an emotion that your adolescent typically feels or exhibits? (Mark all that may apply)
*
Anxiety
Fear
Poor Behavior
Anger
Disconnection
Sadness
Hyperactive
Unmotivated
Frustrated
None of the above. Usually joyful and cooperative.
Food Allergies or Concerns. If none, write N/A or No.
*
I commit to attending all 6 weekly sessions (Every Wednesdays July 2-August 6). If I must miss a session, I will notify the facilitator. I understand there is no-cost to me for this sponsored program, valued at $597. I honor this opportunity made possible by our generous sponsors.
*
Yes
No
Submit
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