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Parent Group Registration

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

PARENTING YOUR GIFTED CHILD: 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. Cost is $450 for one caregiver or $675 for both caregivers.
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 *
All boxes must be checked in order to complete registration.
Confidentiality Agreement *
All boxes must be checked in order to complete registration.
PAYMENT INFORMATION
Method of Payment *
Please select preferred form of payment below. To keep the cost of services down, Venmo @bloompediatrics, PayPal at paypal.me/BloomPediatrics, or check are preferred forms of payment. Invoices are sent via email and payment in full is due when invoice is received unless prior alternate arrangements have been made. Credit card information is required for registration fee and security of payment.
Name on Card *
Name on Card
$450 for one caregiver or $675 for both caregivers
$
Payment Authorization *