Lisa M Stephen, Ph.D. Peak Performance Coach Registration Form - Minor Client First Name:* Client Last Name:* DOB:* Date Format: MM slash DD slash YYYY Date:* Date Format: MM slash DD slash YYYY Client Information Name:* Date of Birth* Date Format: MM slash DD slash YYYY Ethnicity/Race* Street Address:* City* State:* Zip:* Home Phone:* Cell: Gender:*MaleFemale Preferred Pronouns:* School:* Grade:* Parent/Custody Information Name:* Name: Address:* Address: City:* State:* Zip:* City: State: Zip: Home Phone:* Work Phone:* Cell Phone:* Home Phone: Work Phone: Cell Phone: Emergency Notification (Must be a local person.) Name:* Work Phone:* Street Address:* Home Phone:* City:* State:* Zip:* Relationship to Client:* Telephone and Written Communication Dr. Stephen may leave telephone messages for me with her name, telephone number, and information related to appointment dates, times, and changes at the following telephone number(s): Number(s)* Dr. Stephen may send written correspondence to me at the following address: Street:* City:* State:* Zip:* My signature below indicates that the information cited above is true, accurate, and current. Client Signature* Client Name* Date* Date Format: MM slash DD slash YYYY My signature below indicates the information cited above is true, accurate, and current; I am legally allowed to obtain coaching services for: Name of Client:* That if I am required to inform any other party of the client’s participation in coaching services I have done so. Parent/Guardian Signature* Parent/Guardian Name* Date* Date Format: MM slash DD slash YYYY Parent/Guardian Signature Parent/Guardian Name Date Date Format: MM slash DD slash YYYY PO Box 1034, Jericho, VT 05465 • [email protected] • 802-355-9299 • ignitepeakperformance.com BUILDING THE MINDS OF CHAMPIONS PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
