Skip to Content
Appointment
Home
Services
Parents
Schools
Business
Resources
Local Resources
Community Service
About Us
Contact us
Giving Back
Program
Home
Services
Parents
Schools
Business
Resources
Local Resources
Community Service
About Us
Contact us
Giving Back
Program
Appointment
Emotional Synergy Registration Form
FREE Six-Week Program for Parents and their Youth (11-17). Please fill in the form below.
Name of Child (Must be between the age of 11-17).
*
First Name
Last Name
Choose the current age of your adolescent attending with you.
*
Please Select
11
12
13
14
15
16
17
Other
Grade of Child as of August 2025
*
K-1, 2-3, 4-5
Name of Parent/Guardian
*
First Name
Last Name
Parent/Guardian Phone Number
*
Phone Number of Additional Emergency Contact
*
How many children will be attending this event with you? Please complete a separate registration form per child to include the accompanying adult. We recommend, if possible, one adult per child. However, a parent/guardian can attend with a maximum of 2 children.
*
1
2
Other (Please call 786-708-7508 for details or if you require special accommodations).
Email
example@example.com
Name of Additional Emergency Contact
First Name
Last Name
Relation to Child
How often do you and your adolescent do fun activities together?
*
More than 5 times a week
2-4 times a week
Weekly
Other
Which of these describe an emotion that your adolescent typically feels or exhibits? (Mark all that may apply)
*
Anxiety
Fear
Poor Behavior
Anger
Disconnection
Sadness
Hyperactive
Unmotivated
Frustrated
None of the above. Usually joyful and cooperative.
Food Allergies or Concerns. If none, write N/A.
*
I commit to attending all 6 weekly sessions (Every Wednesdays July 3-August 6). If I must miss a session, I will notify the facilitator. I understand there is no-cost to me for this sponsored program, valued at $597. I honor this opportunity made possible by our generous sponsors.
*
Yes
No
Submit
Should be Empty:
Emotional Synergy Registration Form
FREE Six-Week Program for Parents and their Youth (11-17). Please fill in the form below.
Name of Child (Must be between the age of 11-17).
*
First Name
Last Name
Choose the current age of your adolescent attending with you.
*
Please Select
11
12
13
14
15
16
17
Other
Grade of Child as of August 2025
*
K-1, 2-3, 4-5
Name of Parent/Guardian
*
First Name
Last Name
Parent/Guardian Phone Number
*
Phone Number of Additional Emergency Contact
*
How many children will be attending this event with you? Please complete a separate registration form per child to include the accompanying adult. We recommend, if possible, one adult per child. However, a parent/guardian can attend with a maximum of 2 children.
*
1
2
Other (Please call 786-708-7508 for details or if you require special accommodations).
Email
example@example.com
Name of Additional Emergency Contact
First Name
Last Name
Relation to Child
How often do you and your adolescent do fun activities together?
*
More than 5 times a week
2-4 times a week
Weekly
Other
Which of these describe an emotion that your adolescent typically feels or exhibits? (Mark all that may apply)
*
Anxiety
Fear
Poor Behavior
Anger
Disconnection
Sadness
Hyperactive
Unmotivated
Frustrated
None of the above. Usually joyful and cooperative.
Food Allergies or Concerns. If none, write N/A.
*
I commit to attending all 6 weekly sessions (Every Wednesdays July 3-August 6). If I must miss a session, I will notify the facilitator. I understand there is no-cost to me for this sponsored program, valued at $597. I honor this opportunity made possible by our generous sponsors.
*
Yes
No
Submit
Should be Empty:
We use cookies to provide you a better user experience on this website.
Cookie Policy
Only essentials
I agree