Growing Minds Comprehensive 5-day Program Registration - Page 3

Comprehensive Program
Registration Form

Page 3
Email address	* Required Field Please enter email address again
Does your child attend school?	Yes No If yes, please indicate how many hours per week, what type of school / class, number of students in the class, etc. Do you intend to keep your child in this program while doing Growing Minds?
Does your child have any medical conditions or physical limitations that we should be aware of?	Yes No If yes, please explain fully.
Is your child currently on medication?	Yes No If yes, please explain fully.
Does your child have special dietary needs?	Yes No If yes, please explain fully.
Does your child ever behave in ways that are self-injurious or physically aggressive towards others?	Yes No If yes, please describe the behavior and the frequency and intensity with which it occurs.
What about being with your child do you enjoy most?
What do you find most difficult about your being with your child?
What are your goals for this training?
Is there any additional information you believe would be useful for us to know?	Please check if you are an animal. Yes No
Cancelation Policy If you cancel This program: You can choose between a refund or credit for future services if you cancel with 120 days’ notice. If you give 119-60 days notice, you’ll receive a credit for future services. If you give less than 60 days notice, no credit or refund will be given, unless family medical emergency can be substantiated, in which case we will issue a credit only. In all these circumstances, we will attempt to schedule another family in your place. If we are successful, we will issue you a refund. All cancellations and program date changes are subject to a non-refundable $250 administrative fee. In addition, the cost of any bank or credit card charges incurred for receiving and refunding your payment will be subtracted from the refund. Registration Downpayment Payment: A deposit of $1,000 is due upon registering. A second payment of $3,500 is due 120 days prior to the 4-Day program. The balance of $4,700 is due 60 days prior to the 4-Day program. Fees can be paid by check or credit card (Visa or MasterCard). Checks from outside the US must be international money order or cashiers check payable in US currency only. I am sending you a check or money order for $1,000. (Payable in US funds). Please charge the $1,000 deposit to my: MasterCard Visa Credit Card Number: Expiration Date: (month/year: 00/00)