Bloom Pediatrics
Nature. Nurture. Bloom.
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parenting your gifted child group registration fall 2019

Our groups provide a safe and supportive environment to freely discuss your child’s development and parenting challenges. You will connect with other parents, increase your awareness of your child’s unique needs, learn strategies for successful parenting, and expand your resources.

Parenting Your Gifted Child:
GROUP REGISTRATION Fall 2019

PARENTING YOUR GIFTED CHILD: GROUP REGISTRATION FALL 2019 *
Groups are limited to 10 participants. If a group is full, you will be notified via email and placed on a waiting list.
PARTICIPANT INFORMATION
Caregiver #1 Name *
Caregiver #1 Name
Caregiver #1 Phone *
Caregiver #1 Phone
Caregiver #1 Address *
Caregiver #1 Address
Caregiver #2 Name (Optional)
Caregiver #2 Name (Optional)
Caregiver #2 Phone (Optional)
Caregiver #2 Phone (Optional)
Group Participants *
Who is registering for this group?
CHILD INFORMATION
Child #1 Name *
Child #1 Name
Child #1 Date of Birth *
Child #1 Date of Birth
Child #2 Date of Birth
Child #2 Date of Birth
Child #3 Name
Child #3 Name
Child #3 Date of Birth
Child #3 Date of Birth
ADDITIONAL INFORMATION
Please answer the following questions to help us better understand your needs and create a positive group experience.
REQUIRED FORMS - PLEASE READ CAREFULLY
Financial Agreement *
All boxes must be checked in order to complete registration.
Confidentiality Agreement *
All boxes must be checked in order to complete registration.
PAYMENT INFORMATION
Method of Payment *
Please select preferred form of payment below. To keep the cost of services down, Venmo @bloompediatrics, PayPal at paypal.me/BloomPediatrics, or check are preferred forms of payment. Invoices are sent via email and payment in full is due when invoice is received unless prior alternate arrangements have been made. Credit card information is required for registration fee and security of payment.
Name on Card *
Name on Card
Today's Date
Today's Date
$350 for one caregiver or $500 for both caregivers
$
Payment Authorization