Summer Group Registration Form Group Therapy Registration Register for Summer Group Therapy Child's Name(Required) First Last Child's Date of Birth MM slash DD slash YYYY Guardian's Name(Required) First Last Guardian's Relationship to Child(Required)Phone(Required)Okay to Call and/or Text(Required) Okay to Leave a Voicemail AND okay to Text Okay to Leave a Voicemail but do NOT Text Okay to Text but do NOT call nor leave a Voicemail Other Email(Required) Enter Email Confirm Email Okay to Email?(Required) YES NO Other Which Group Do You Wish to Register for?(Required) Girls 10-12 years old (Wednesdays 11:00-12:00) Summer, 2024–start anytime Girls 15-17 years old (Wednesdays 1:00-2:00) Summer, 2024–start anytime Boys 7-9 years old (Wednesdays 2:00-3:00) Summer, 2024–start anytime Mini Therapy Camp 4-7 year olds (July 18 & 19, 2024 from 9:00-12:00 both days) If able, would you like to utilize your insurance to cover the cost of the therapy groups? (Not available for MIni-Therapy Camp)(Required) YES NO Unsure If you hope to utilize insurance, please provide your insurance information including the name of the insurance, the member ID, the name of the subscriber, and the subscriber's date of birth. Thank you.Please tell me a little about your child including anything you believe I would need to know for them to enjoy group. We will still talk and meet individually before they begin group.(Required)What are you registering for?(Required) Therapy Group (Non-refundable Deposit Required $50.00) Mini-Therapy Camp (Payment in full: $125.00) Total Credit Card(Required)