Parenting Workshop

Name

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Phone

Optional Donation

Number of children attending that will need childcare (INCLUDED IN THE COST OF THE SEMINAR)

I acknowledge that the services being provided are in no way related to the presenters area of licensure, and that we are in a group setting where there are risks involved. I accept these risk and understand that the quality and outcomes of these services may differ from those typically associated with counseling services. I understand and agree that the services provided in this context are not intended to replace or serve as professional counseling or therapeutic services. I acknowledge that no counseling relationship is being formed through these services. I understand that by completing this form I am agreeing to these terms and accepting liability.

I acknowledge

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

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Parenting Workshop

Description

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