Power of Me for Girls STP | Mad Hatter Wellness

Participant Information

Participant Name*

First Last

Birthdate*

Grade entering in 2018-19 school year*

How did you hear about The Power of Me?

Friend's name

Social worker / therapist's name

Parent / Guardian Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact Name*

First Last

Emergency Contact Relationship to Child*

Emergency Contact Phone Number*

Payment Options*

Month attending