Summer 2015 S.O.S.

S.O.S. - Sisters of Strength

Young Women's Group

Summer 2015 Online Registration Form

The S.O.S. - Sisters of Strength Group will be held on

Thursday Evenings from 6:00 PM to 7:00 PM

at ASPIRE Center in Melville, NY on the following dates:

7/9 * 7/16 * 7/23 * 7/30 * 8/6 * 8/13

Group Policies and Registration Information

Submission of this completed registration form, accompanied by a non-refundable $50 deposit (must be received within 48 hours of form submission) guarantees your place will be held for participation in this group.

The fee for the 6-week cycle is $330.00. An initial payment of $200.00 is prior to attendance at Session 1 (7/9/15), and the remaining $130.00 is due prior to attendance at Session 4 (7/30/15). Payment provided in-person or via postal mail may be submitted by cash, check, or credit card (Visa/Mastercard/Discover). Online payments are processed through PayPal (account or any major credit card).

Special Offer: Receive a $25 discount if payment for cycle is submitted in full at the time of registration.

Pre-planned absence policy: As a courtesy to participants who may be traveling or have another previously scheduled summer obligation that conflicts with group, indication of one pre-planned absence at the time of registration will result in a $50 fee reduction (deducted from 2nd payment) for the missed session.

ASPIRE Center is not an in-network provider for any health insurance plans. However, clients are provided with detailed documentation at the conclusion of the group cycle that may be submitted to an insurance carrier for out-of-network reimbursement (if applicable). ASPIRE Center does not assume responsibility for claim submission or related correspondence with insurance companies.

Please note: group payments are non-refundable; under extenuating circumstances, center credit may be provided as determined on a case-by-case basis.

Have you participated in previous programming at ASPIRE Center OR attended a screener session within the past 12 months?*

YesNo

Thank you for your interest in the S.O.S. - Sisters of Strength group at ASPIRE Center.

We are committed to ensuring that groups are a strong match for each member and, therefore, have implemented a brief screening process for all new participants. Prior to enrollment, a member of our clinical team will collect initial information and conduct a 30-minute meeting to assess group fit based on your strengths and goals.

Please CLICK HERE to submit a screener request form.

Alternately, you may contact ASPIRE Center directly by telephone at (631) 923-0923 or via email at info@aspirecenterforlearning.com.

We look forward to meeting you!

Registration Information

Client Information

Client Name*

First NameLast Name

Date of Birth*

MonthDayYear

Age*

E-mail Address*

Phone Number*

Area CodePhone Number

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent Information (if applicable)

Parent Name(s)

First NameLast Name

Parent E-mail

Parent Phone Number

Area CodePhone Number

Will you be indicating a pre-planned absence?

NoYes

Please select date of pre-planned absence:

Please sign below (by holding down button on mouse or trackpad) to indicate consent for group participation, acknowledgement of the group policies, and acceptance of payment responsibilities as outlined in the initial section of this form.

Please select your payment method*

Submit full group payment ONLINE ($25 discount!)$305.00

Submit Full Cycle Payment ($25 discount) with pre-planned absence - ONLINE$255.00

Submit first payment ONLINE$200.00

Submit non-refundable deposit ONLINE$50.00

Submit payment IN-PERSON (must receive within 48 hours)$ Free

Submit payment via postal mail (must receive within 48 hours)$ Free

Questions? Please feel free to contact us at any time!

Telephone: (631) 923-0923

E-mail: info@aspirecenterforlearning.com

We look forward to seeing you soon!