Participant Information

Group Registration
Which Group Are You Registering For?

Grief Adult Support Group-Beginning January 23rdBuilding Up Kids: Battling Big Emotions-Beginning January 25th
GROUP PARTICIPANT'S INFORMATION:
Name of Group Participant*

First Name Last Name
Name of Parent/Guardian of Group Participant (if applicable)

First Name Last Name
Age:*
Sex:*
Address:*
City:*
State:*
Zip Code:*
Participant/Parent/Guardian Phone Number*
Participant/Parent/Guardian E-mail:*
Additional Information/Notes:
Please briefly explain why you are interested in attending this group:
Payment Informaiton
A one-time payment is required prior to beginning the group and no other payment is required. If for any reason you will not be partaking in the group, you will be refunded the full amount.
*
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Grief Support Grief$150.00
8 Week Adult Group

Building Up Kids: Battling Big Emotions $120.00
6 Week Kids Group

Total $0.00
Should be Empty:

Payment Informaiton