Physically Distancing, Socially Connecting Registration

Physically Distancing, Socially Connecting Registration Form

Fill out the form carefully for registration
Student Name

First Name Middle Name Last Name
Birth Date

Month Day Year
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Student E-mail
Student Mobile Number

Area Code Phone Number
Parent/Guardian Name

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

Area Code Phone Number
I, the above named parent/guardian, give my permission for the above named student to participate in Physically Distancing, Socially Connecting Bootcamp - 4 week Peer Group, Coach Led Mastermind Group. This is agreement will stand should the participant agree to continue beyond 4 weeks. I understand that this is a Coaching format, not counseling.
I, the above named parent/guardian, give my permission for the above named student to participate in Physically Distancing, Socially Connecting- 4 week Peer Group, Coach Led Mastermind Group. I fully understand that this is a coaching group and not counseling. This 4 week series will be held virtually via computer/phone. This agreement will stand should the participant agree to continue beyond the initial 4 weeks.

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Physically Distancing, Socially Connecting Bootcamp $ 39.95

Total $ 0.00

Physically Distancing, Socially Connecting Registration Form