Group Application 2022-2023
Hello! Thank you for filling out our application for all groups Fall 2022- Spring 2023. All information below will remain confidential. Your contact information will only be used to create a group email for parents & guardians. Youth information will only be used to create a group text, upon permission at the start of the group. If once complete you still have questions, please indicate YES to a free 20 minute phone conversation. Thank you. We look forward to sharing this powerful journey with your family :)
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Parent / Guardian Name *
Email *
Phone Number *
Address *
Participant's Name *
Participant's Email
Participant's Phone Number
Participant's School *
Participant's Birthday *
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/
DD
/
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Grade Fall 2022 *
Yes, I understand the program, and our intention is to participate in all that we can. (Full details on website) * *
We are signing up for *
Payment Method *
Please share any questions you may have, or information about your daughter and family that might be useful to us as their guides and as we consider your application. This would include hopes and wishes, challenges, family structure, trauma history, medications, mental health concerns or diagnosis, hospitalization history/concerns, or special needs. *
Which of the following best represents your daughter's racial or ethnic heritage? Choose all that apply.
Will your teen have received the Covid vaccine and booster by the first meeting on the weekend of 9/17-9/18? *
I would like to schedule a free 20 minute phone conversation upon review of my application. *
How did you hear about us?   *
Required
* * * PLEASE CLICK THE SUBMIT BUTTON BELOW * * *
Thank you! We will get back to you as soon as we've had a chance to review your application.
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