Circle Of Security Parenting Group Registration

Circle Of Security Parenting Group Registration
Welcome

We're looking forward to having you join our Circle of Security Parenting group! Please complete the form below to finalize your registration and reserve your spot.

Registration, Payment, and Cancellation Policy

1. Registration & Enrollment
- Enrollment is first-come, first-served and space is limited.
- A participant’s spot is not guaranteed until full payment is received.
- Registration is considered complete and binding upon payment.
2. Payment Policy
- Full payment is required at the time of registration to reserve a spot.
- Payment confirms commitment to the full 8-week program.
- No refunds or credits for missed sessions or early withdrawal
- This session is offered as private pay (out of pocket) service. Private insurance will not be billed.
3. Attendance & Participation Expectations
- This is an 8-week structured program, and consistent attendance is important for success.
- Missed sessions:
  - Are not refunded
  - Cannot be made up unless otherwise specified
- If a session is cancelled by the Instructor (due to illness, etc.) a make-up session will be offered.
4. Childcare
- This group is designed for parents and caregivers. Childcare is not provided during group sessions.
Caregiver Name (Enrollee)

First NameLast Name
Child's Name (Youth Clinic Patient)

First NameLast Name
Email
example@example.com
Will an additional caregiver be participating in this group?
Caregiver 2 Name

First NameLast Name
Caregiver 2 Email
example@example.com
Two caregivers from the same family are welcome to participate. All registered participants are expected to attend each session rather than alternating attendance.
Is your child on Medicaid or CHP+?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

By registering for the program, participants acknowledge that they: Understand and agree to all payment and cancellation terms Are committing to the full 8-week experience and that Private Insurance will not be billed.

8 Week Parenting Class

$500.00

Total

Credit Card

Next Steps
- After we receive your completed registration and payment, our team will schedule your group appointments. Once scheduled, appointments will appear under your child's account in My Health Connections.
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Circle Of Security Parenting Group Registration

By registering for the program, participants acknowledge that they: Understand and agree to all payment and cancellation terms Are committing to the full 8-week experience and that Private Insurance will not be billed.*

Credit Card

By registering for the program, participants acknowledge that they: Understand and agree to all payment and cancellation terms Are committing to the full 8-week experience and that Private Insurance will not be billed.