Summer Support Group for Teen Adoptees

Summer Support Group for Teen Adoptees
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Please select the date(s) you will be registering and paying for:*

June 2June 9June 16June 23July 7July 14July 21July 28
Would you like us to bill your insurance for this program?(We currently bill Blue Cross and Blue Shield only.)*

YesNo
If Yes, please provide the following information:
Member ID
Primary Insurance Holder (if different from the participant):
Name of Primary Insurance Holder:
Date of Birth of Primary Insurance Holder:

MonthDayYear
Date
Are you currently receiving services with our organization and already approved for the Lifesong scholarship?

YesNo
If YES: We will use the scholarship information already on file. No additional application is needed, and a member of our team will be reaching out with more information regarding the out‑of‑pocket cost.

If NO: A scholarship application will be sent to you by email. Please watch for this email and complete the application to be considered.
Private Pay- I choose private pay and will proceed to payment to complete registration.

YesNo

My Products

June 2nd Class- SUMMER SUPPORT GROUP FOR TEEN ADOPTEES

$42.00 Quantity

June 9th Class- SUMMER SUPPORT GROUP FOR TEEN ADOPTEES

$42.00 Quantity

June 16th Class- SUMMER SUPPORT GROUP FOR TEEN ADOPTEES

$42.00 Quantity

June 23rd Class- SUMMER SUPPORT GROUP FOR TEEN ADOPTEES

$42.00 Quantity

July 7th Class- SUMMER SUPPORT GROUP FOR TEEN ADOPTEES

$42.00 Quantity

June 14th Class- SUMMER SUPPORT GROUP FOR TEEN ADOPTEES

$42.00 Quantity

July 21st Class- SUMMER SUPPORT GROUP FOR TEEN ADOPTEES

$42.00 Quantity

July 28th Class- SUMMER SUPPORT GROUP FOR TEEN ADOPTEES

$42.00 Quantity

June 2nd Class- SUMMER SUPPORT GROUP FOR TEEN ADOPTEES

$42.00 Quantity

Total

$0.00