Making Friends With Yourself 8-Week Class for Teens 14-18, Fall 2016 September 2016 REGISTRATION FORM Please note: This information will only be read by the course instructors. If you feel uncomfortable answering any questions, please note that on the form and we can have a private conversation before the program begins. Leaving a question blank will have no impact on inclusion in the program. Thank you.Parent or guardian information:Name of Parent/Guardian* Parent/Guardian Email* Parent/Guardian preferred phone*How do you hope your teen will benefit from this class? What are your expectations and desires for your teen?*Is there anything you think we should know about your teen that would make it a better experience for them, the group, and the teachers?*Examples would be letting us know about any special learning needs, any recent traumas or major disruptions, any particularly vulnerable areas, any notable areas of strength or interest, etc.How did you hear about this course? Please be as specific as possible.*Ex: Past participant, Google search, flier, your employer, CMSC website, etc.Teen InformationName of Teen* First Last Phone (cell)*Phone (home)*Teen's Email* Date of birth MM slash DD slash YYYY Your gender Female Male How would you like to get reminders about the course during the week?*Please note that we will never share your contact information. Text Email Why are you interested in participating in this program?*How would you describe your physical health?*excellentgoodfairpoorAre you currently in psychotherapy? If so, please provide the name and telephone number of your therapist.Are you currently taking psychoactive medication, or any medication that may affect how you feel from one week to the next? (If so, please provide details.)*If there is anything else that would be helpful for the instructors to know at this time, please let us know here.Would you like to receive our occasional newsletters and updates?*No worries. We'll never share your email address. Yes, please. No, thanks. Agreements (Adult and Teen):TEEN: I understand that my participation in this program is entirely voluntary and I am free to withdraw at any time without penalty or prejudice, except for the non-refundable course fee. At the present time, however, I am planning to participate in the entire course, and to practice mindful self-compassion at least 30 min/day (formally or informally). I understand that this is not a group therapy program.* I agree I do not agree TEEN SIGNATURE: By signing below, I agree that all information above is true to the best of my knowledge.*You may use your mouse, trackpad, or finger to sign your name in the space above. Thank you! Reset signature Signature locked. Reset to sign again ADULT: I understand that my child’s participation in this program is entirely voluntary and they are free to withdraw at any time without penalty or prejudice, except for the non-refundable course fee. I understand that this is not a group therapy program, and that my child is accountable for their involvement in the course.* I agree I do not agree ADULT SIGNATURE: By signing below, I agree that all information above is true to the best of my knowledge.*You may use your mouse, trackpad, or finger to sign your name in the space above. Thank you! Reset signature Signature locked. Reset to sign again Date of signing* MM slash DD slash YYYY Payment Details:We offer two ways to cover the cost of this course: a) $295, or b) via the pay-it-forward method in which the teen works in the community for at least 8 hours. How do you wish to pay?* 8 hours of community service via check the first day of class CommentsThis field is for validation purposes and should be left unchanged.