2017 YA Summer Program

Summer 2017

Summer Days Skill Building

Co-ed Half-Day Program for Young Adults

Online Registration Form

Summer Days Skill Building will be held during 4 weeks of Summer 2017 on Tuesday and Thursdays from 1:00pm-4:00pm.

Sessions:

7/18

7/20

7/25

7/27*

8/1

8/3

8/8

8/10*

*These sessions will be community-based. Each participant will be responsible for transportation and cost of food/drinks during outings.

Summer Program Policies and Registration Information

Submission of this completed registration form, accompanied by a non-refundable $100 deposit (must be made through PayPal) guarantees your place will be held for participation in this summer program.

The fee for the 4-week half-day program is $1,200.00. Payment must be made in full by Wednesday, July 5th. Payment provided in-person or via postal mail may be submitted by cash, check, or credit card (Visa/Mastercard/Discover). Online payments are processed through PayPal (account or any major credit card).

*Special Offer* Receive a $100 discount if payment for program is submitted in full at the time of registration.

ASPIRE Center is not an in-network provider for any health insurance plans. However, clients are provided with detailed documentation at the conclusion of the summer programming that may be submitted to an insurance carrier for out-of-network reimbursement (if applicable). ASPIRE Center does not assume responsibility for claim submission or related correspondence with insurance companies.

Please note: summer programming payments are non-refundable; under extenuating circumstances, center credit may be provided as determined on a case-by-case basis.

Have you participated in previous programming at ASPIRE Center OR attended a screener session within the past 12 months?*

YesNo

Thank you for your interest in the Summer Days Skill Building, a young adult summer program at ASPIRE Center.

We are committed to ensuring that groups are a strong match for each member and, therefore, have implemented a brief screening process for all new participants. Prior to enrollment, a member of our clinical team will collect initial information and conduct a 30-minute meeting to assess group fit based on your strengths and goals.

Please CLICK HERE to submit a screener request form.

Alternately, you may contact ASPIRE Center directly by telephone at (631) 923-0923 or via email at info@aspirecenterforlearning.com.

We look forward to meeting you!

Registration Information

Client Information

Client Name*

First NameLast Name

Date of Birth*

MonthDayYear

Age*

Phone Number*

Area CodePhone Number

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail Address*

Parent Information (if applicable)

Parent Name(s)

First NameLast Name

Parent E-mail

Parent Phone Number

Area CodePhone Number

Please sign below (by holding down button on mouse or trackpad) to indicate consent for group participation, acknowledgement of the group policies, and acceptance of payment responsibilities as outlined in the initial section of this form.*

My Products*

Submit payment ONLINE (Pay in Full-$100 discount!)$1,100.00

Submit deposit for program ONLINE$100.00