Teen Life Skills Workshop 2023 | Powerful Education Solutions

Child's Full Name

Street Address

City

Region/State/Province

Postal / Zip code

Age

Date of Birth

Current Grade

Other Programs Currently Attending

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Phone

Street Address

City

Region/State/Province

Postal / Zip code

Additional contacts if primary parent/guardian cannot be reached. At least one emergency contact must be listed.

Emergency Contact Full Name

Phone

Emergency Contact #2 Full Name

Phone

Please list any allergies and/or food intolerances here and actions to be taken if emergency occurs.

Please list any physical or developmental problems that may need special accomodations during camp. (i.e. Sensory issues, anger management, etc)

If yes above, click here to download medical form. Upload completed form below.

If answered YES above, please click here to download medical form. Please e-mail completed form to office@loristephensllc.com prior to camp dates.

Please add any additional requests and notes here.

We accept PayPal and all major credit cards. If you do not have a PayPal account or wish to pay with a card, choose "Pay with Debit or Credit."

Need help? Send us a message here.

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Teen Workshop 7/10-7/14 - $500