DBT Skills Building Teen Workshop Registration

We are so pleased that you are interested in our DBT Skills Building Teen Workshop, being held on July 21st, 2022 from 10:00am – 1:00pm.

Registration is open now through July 18, 2022. Registration is $125 per attendee, and includes a workbook, workshop presentations, and light refreshments. For any questions, please contact rujuta@mindfulgrouppractice.com.

DBT Skills Building Workshop for Teens Registration

Registrant Information

Please provide the contact information of the adult registering for the teen participant(s).

Parent/Guardian Name(Required)

Please enter the name of the adult registrant.

First Last

Email Address(Required)

Phone Number

Address(Required)

Street Address Address Line 2 City State ZIP Code

Teen Participant Information

DBT Workshop for Teens Registration

How many teens are you registering?(Required)

Registration fee is $125 per teen participant. Up to 4 participants may be registered per form.

Teen Participant Name(Required)

First Last

Participant Email Address(Required)

Participant Date of Birth(Required)

Gender

Preferred Pronouns

Participant Medical Information

Please let us know of any allergies or related medical conditions.

Emergency Contact Information(Required)

Please provide the name and telephone number of contacts who may be reached in case of emergency for this participant during the time of this workshop. To add additional contacts, press the plus (+).

Name

Relationship

Phone Number

Teen Participant #2 Name(Required)

First Last

Participant #2 Email Address(Required)

Participant #2 Date of Birth

Participant #2 Gender

Participant #2 Preferred Pronouns

Participant #2 Medical Information

Please let us know of any allergies or related medical conditions.

Participant #2 Emergency Contact Information(Required)

Please provide the name and telephone number of contacts who may be reached in case of emergency for this participant during the time of this workshop. To add additional contacts, press the plus (+).

Name

Relationship

Phone Number

Teen Participant #3 Name(Required)

First Last

Participant #3 Email Address(Required)

Participant #3 Date of Birth(Required)

Participant #3 Gender

Participant #3 Preferred Pronouns

Participant #3 Medical Information

Please let us know of any allergies or related medical conditions.

Participant #3 Emergency Contact Information(Required)

Please provide the name and telephone number of contacts who may be reached in case of emergency for this participant during the time of this workshop. To add additional contacts, press the plus (+).

Name

Relationship

Phone Number

Teen Participant #4 Name(Required)

First Last

Participant #4 Email Address(Required)

Participant #4 Date of Birth(Required)

Participant #4 Gender

Participant #4 Preferred Pronouns

Participant #4 Medical Information

Please let us know of any allergies or related medical conditions.

Participant #4 Emergency Contact Information(Required)

Please provide the name and telephone number of contacts who may be reached in case of emergency for this participant during the time of this workshop. To add additional contacts, press the plus (+).

Name

Relationship

Phone Number

Additional Information & Waivers

Please provide any additional information about this registration you would like us to know (optional)

How did you hear about this workshop?(Required)

Mindful Group Practice Website

Online Search

Social Media

Other

COVID-19 Liability Waiver(Required)

I acknowledge the contagious nature of the Coronavirus/COVID-19.

I further acknowledge that Mindful Group Practice LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.

I further acknowledge that Mindful Group Practice LLC cannot guarantee that I will not become infected with the Coronavirus/Covid-19.

I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other clients and their families.

I voluntarily seek services provided by Mindful Group Practice LLC and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19.

I acknowledge that I must comply with all set procedures to reduce the spread while attending workshop.

I agree to the Liability Waiver.

Participation Waiver(Required)

I acknowledge that my participant is participating voluntarily in this workshop.

I understand that this is a workshop that focuses on learning skills and that this is not group therapy for teenagers.

I understand that interaction in this workshop is not confidential.

I will not hold Mindful Group Practice liable for any injury on the premises.

I will not hold Mindful Group Practice liable for psychological injury, pain, or suffering

I agree to the Participation Waiver.

Payment Information

Total Amount Due

Credit Card

Card Details

Cardholder Name

Address

Same as mailing address above

Street Address Address Line 2 City State ZIP Code