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Parent Group Registration

Parenting Your Gifted Child: A SENG-Model Parent Group REGISTRATION

Groups are limited to 10 participants. If a group is full, you will be notified via email and placed on a waiting list.
PARTICIPANT INFORMATION
Caregiver #1 Name *
Caregiver #1 Name
Caregiver #1 Primary Phone *
Caregiver #1 Primary Phone
Caregiver #2 Name
Caregiver #2 Name
Caregiver #2 Primary Phone
Caregiver #2 Primary Phone
Group Participants *
Child #1 Name *
Child #1 Name
Child #1 Date of Birth *
Child #1 Date of Birth
Child #2 Name
Child #2 Name
Child #2 Date of Birth
Child #2 Date of Birth
Child #3 Name
Child #3 Name
Child #3 Date of Birth
Child #3 Date of Birth
PLEASE TELL US A LITTLE ABOUT YOURSELF
REQUIRED FORMS: PLEASE READ CAREFULLY
Financial Agreement *
PAYMENT IN FULL IS DUE UPON REGISTRATION. MISSED SESSIONS CANNOT BE RESCHEDULED AND FEES CANNOT BE PRORATED. WE DO NOT OFFER REFUNDS. WE DO NOT OFFER TRIAL SESSIONS. To keep the cost of services down, cash or check is the preferred form of payment. You may also pay with Venmo @bloompediatrics, PayPal at paypal.me/BloomPediatrics, or online using a credit card. All invoices are sent via email. Credit card information is required for security of payment. Your credit card will NOT be charged to be placed on a waiting list. If a group is full and a spot becomes available, Bloom will contact you to confirm registration. By checking the box below, I acknowledge and understand that a $35.00 service fee will be charged for any checks or payments returned for insufficient funds. I understand that finance charges will accrue at 12% APR if payment is not received in our office within 5 days of the due date, and a minimum monthly finance charge of $5.00 will apply to all overdue payments. I understand that if my account is 30 days past due, Bloom will automatically charge the credit card on file to cover my outstanding balance. Balances exceeding $1000.00 will result in services being placed on hold until a payment plan has been established. Bloom reserves the right to terminate treatment if payment for services is not received. Invoices more than 90 days past due are considered to be in default. I understand that I will be charged cost recovery fees if Bloom must take collection action to resolve payment delinquencies. Cost recovery fees may include small claims fees, attorney fees, enforcement fees, collections fees and lien fees.
Confidentiality Agreement *
Confidentiality is the shared responsibility of all group members and facilitators. Although group facilitators will not disclose group communications or information, group members’ communications and information are not protected. Thus, this agreement is an attempt to provide you and your fellow group members with as much confidentiality protection as possible.
PAYMENT INFORMATION
PAYMENT IN FULL IS DUE UPON REGISTRATION. MISSED SESSIONS CANNOT BE RESCHEDULED AND FEES CANNOT BE PROERATED. WE DO NOT OFFER REFUNDS. WE DO NOT OFFER TRIAL SESSIONS. Credit card information is required for security of payment. Your credit card will NOT be charged to be placed on a waiting list. If a group is full and a spot becomes available, Bloom will contact you to confirm registration.
Method of Payment *
To keep the cost of services down, cash or check is the preferred form of payment. You may also pay with Venmo @bloompediatrics or PayPal at paypal.me/BloomPediatrics. NO CHARGES WILL BE MADE UNTIL REGISTRATION IS CONFIRMED WITH BLOOM.
Name on Card *
Name on Card
$350 for one caregiver or $500 for both caregivers
$
Payment Authorization *