Teen Girl Glow Up Registration — Minaret Therapeutic Services

Teen Girl Glow Up Group 5-Week Program Summer Cohort beginning July 10th- August 7th 2022, 1-5pm in Parker, Colorado. Register Below!

Participant's Name

First Name

Last Name

Participant's Date of Birth

YYYY

Participant's Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Participant's Current Grade Level

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Parent/Guardian's Phone Number

(###)

###

####

Parent/Guardian Email

Hey teen/parent/guardian! What goals would you like to meet during this Teen Girl Glow Up group?

Hey teen/parent/guardian! Please tell us a few things about your teen including any sensory sensitivities, allergies, special dietary needs, or any additional information you find that might be helpful

Does your teen has a official mental health diagnosis? If so, please list both current and past diagnoses here

What form of payment is preferred?

Please choose an option that works best for you in terms of payment. Please note, total payment is due after registration/prior to the beginning of this program. If you select cash or check, this payment needs to be delivered after registration/prior to the program. Minaret Therapeutic Services will contact you via phone or email regarding payment drop-off, thank you!

Cash

Check

Debit/Credit Card

Venmo

Zelle

How did you hear about this group?

If you were referred to this group or have selected other, please let us know who referred you or where you found out about this group in the additional information section of this form. Thank you!

If you or your teen have any additional information or comments, please list here

I acknowledge that this program does not and shall not tolerate any discrimination on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, in any of its activities or operations.

Yes

I acknowledge that with registering for this program, I/my child are committing to all session dates included. I further acknowledge that if I/my child misses any of the scheduled session dates, that I understand that the full benefits of the program may not apply and that I do not hold Minaret Therapeutic Services or Colorado Equine Specialist liable for any missed benefits or consequences from missing sessions.

Yes

Let’s Talk!