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    Lisa M Stephen, Ph.D.

    Peak Performance Coach

     

    Registration Form - Minor


     
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  • Client Information

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  • Parent/Custody Information

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  • Emergency Notification (Must be a local person.)

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  • 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):


  • Dr. Stephen may send written correspondence to me at the following address:

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  • My signature below indicates that the information cited above is true, accurate, and current.

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  • My signature below indicates the information cited above is true, accurate, and current; I am legally allowed to obtain coaching services for:

  • That if I am required to inform any other party of the client’s participation in coaching services I have done so.

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    PO Box 1034, Jericho, VT 05465 • drstephen@ignitepeakperformance.com • 802-355-9299 • ignitepeakperformance.com

      BUILDING THE MINDS OF CHAMPIONS
     
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