MePowerment Peer Led, Coach Facilitated Registration

MePowerment Peer Led Coach Facilitated Community Registration Form

Fill out the form carefully for registration
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student E-mail
Student Mobile Number

Area CodePhone Number
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number

Area CodePhone Number
I, the above named parent/guardian, give my permission for the above named student to participate in MePowerment Programs 6 week Peer Led, Coach Facilitated Community. I fully understand that this is a coaching group and not counseling. This 6 week series will be held virtually via computer/phone. This agreement will stand should the participant agree to continue beyond the initial 6 weeks.

MePowerment Peer Led, Coach Facilitated Community$119.00

Total $0.00

MePowerment Peer Led Coach Facilitated Community Registration Form