Girl-Talk Summer Group - 2015 Registration Form

ASPIRE Center for Learning and Development
Teen Girl-Talk Summer Group

Online Registration Form
The Teen Girl-Talk summer group will be held

Wednesday Evenings from 7:15 PM - 8:15 PM on the dates listed below:
July

15th

22nd

29th

August

5th

12th

19th

26th

September

2nd
Group Policies and Registration Information
Program Fee: The full fee for the 8-week summer cycle is $440.00.

Payment Options and Fee Details: Participants who submit the full cycle fee at the time of registration will receive a $25 discount. Payment will also be accepted in two installments: $275.00 is due prior to attendance at Session 1 (7/13/15), and the remaining $165.00 is due prior to attendance at Session 4 (8/3/15).

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). Submission of this completed registration form, accompanied by a non-refundable $50 deposit (must be received within 72 hours of form submission) guarantees your place will be held for participation in this group.

Should you opt to submit the cycle fee in two installments, authorization will be requested prior to the first session for a one-time automatic credit card charge to ensure timely receipt of second installment. This policy has been implemented for mutual convenience, and credit card on file will be charged only if second installment is not received within 24 hours of the aforementioned due date.

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.
Child Information
First Name*
Last Name*
Date of Birth:*

MonthDayYear
Date
Age*
Allergies or Other Pertinent Medical Notes:
Parent Information
First Name*
Last Name
Street Address*
City*
State*
Zip Code*
E-mail Address*
Preferred Telephone Number*
Has your child 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 Teen Girl-Talk Summer Group at ASPIRE Center.

We are committed to ensuring that groups are a strong match for each members 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 with you and your child to assess group fit based on your child's strengths and goals.

To schedule a screener for this group, please CLICK HERE to submit a request form. Alternately, you may contact ASPIRE Center directly by telephone (631-923-0932) or e-mail (info@aspirecenterforlearning.com).

We look forward to meeting you!
Will you be indicating a pre-planned absence?*

YesNo
Please select date of pre-planned absence:

July 15thJuly 22ndJuly 29thAugust 5thAugust 12thAugust 19thAugust 26thSeptember 2nd
Please SIGN AND DATE below (by holding down button on mouse or trackpad) to indicate consent for your child's group participation, acknowledgement of the group policies, and acceptance of payment responsibilities as outlined in the earlier section of this form.*

Clear
Please select from the following payment options (online credit card payments will be processed through PayPal on separate page):*
prevnext( X )
Submit Full Cycle Payment ($25 discount) - ONLINE$415.00

Submit Full Cycle Payment ($25 discount) with pre-planned absence - ONLINE$365.00

Submit First Installment Only - ONLINE$275.00

Submit Deposit Only - ONLINE$50.00

Submit Payment via POSTAL MAIL (must be received within 72 hours)$ Free

Submit Payment IN PERSON (must be received within 72 hours)$ Free
Questions? Please feel free to contact us at any time!

Telephone: (631) 923-0923

Fax: (631) 923-0924

E-mail: info@aspirecenterforlearning.com

The ASPIRE Center Clinical Team
Please click "Proceed to Checkout" in order to submit your registration form to ASPIRE Center. If you have chosen to provide payment by credit card or through your PayPal account, you will be taken to a new web page for online payment. A confirmation email will follow, which contains group details, dates, and policies.
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Teen Girl-Talk Summer Group