Insight Program for Teen Drug Prevention Sign-up Form
This is an initial pre-registration form to send information to the program counselor for Insight. Students must be approved for the program in advance. All classes will be held at Willowstone Family Services, 615 N. 18th Street, (Howarth Center) Suite 101, Lafayette, IN 47904. If you have questions about this program or need information regarding the requirements please contact our office at 765-423-5361, or email Sara Tyner at sara2@willowstone.org.
Parent/Guardian First Name *
Your answer
Parent/Guardian Last Name *
Your answer
Youth First Name *
Your answer
Youth Last Name *
Your answer
Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Phone number *
Your answer
Which program session do you want to attend? *
What do you hope to achieve from this program?
Your answer
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