Girl Warriors Workshops — Counseling Associates at the Lake, Inc.

Child's Name

First Name

Last Name

Age

Rising Grade

School

Parent's Name/s

Parent's Phone Number

(###)

###

####

Home Address

Emergency Contact

Please provide both the full name and phone number of child's emergency contact (other than parent).

Workshop Registration

Please select which workshop you are registering for.

7/23 - 7/26 10:00am - 12:15pm daily

7/18 - 8/15 every Wednesday 6:00-7:45pm

8/6 - 8/9 10:00am - 12:15pm daily

Tell us a little about your daughter….her personality, any important or relevant information that may be helpful for us to know, any specific topics of the workshop you think would be most helpful to her, etc. This is confidential information….just anything that may be helpful for the co-facilitators to know about your daughter that would help us make the workshops the most beneficial for her!

Payment of $240 is due upon registration to hold your daughter’s spot. (Remember….you receive an additional 10% off for each other child or sibling you refer who registers. Your discounts can be paid back to you later once it is confirmed how many other participants you referred who registered) Payment and registration form must be received to reserve your daughter’s spot.

You may pay over the phone by credit card by calling Michelle Smith at 704-301-5424 or you can send your payment in the mail with check to :

Counseling Associates at the Lake, Inc.
19501 W. Catawba Ave
Mailbox 10
Cornelius, NC 28031

**Healthy snacks and waters will be provided. Please let us know if your daughter has any allergies or food restrictions. Feel free to send your daughter with a snack of her own if you so desire**

We are SO excited your daughter will be participating in this wonderful workshop series! We are looking so forward to meeting your beautiful and strong “GIRL WARRIOR”!!!!!!

Serving the Lake Norman area since 2003.

(704) 301.5424 | mjlsmithlcsw@caatl.net
19501 W CATAWABA AVE. MAILBOX 10 CORNELIUS, NC 28031

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