Family Registration - Sunshine Prevention Center

Family Registration Form

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For Office Use Only

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Amount of Deposit

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Check #

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Venmo

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Cash

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Requesting Payment Plan

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Requesting Sponsorship

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Outside Agency Making Payment

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If Yes, Agency Name

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If Yes, Contact Name

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If Yes, Email

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If Yes, Phone

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Is this is a re-registration?

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(Staff Only) ID #

Participant Information

Participant Name(Required)

First Last Name

Gender(Required)

Age(Required)

Birthdate(Required)

Grade

Races(s)(Required)

Have you attended an Initial Family Assessment?(Required)

Yes

If so, what was the date?(Required)

Parent 1

Name(Required)

First Last

Email(Required)

Phone 1 (home/work/cell)(Required)

Phone 2 (h/w/c)(Required)

Parent 2

Name

First Last

Phone 1 (home/work/cell)

Phone 2 (h/w/c)

Participant lives with...(Check All That Apply)(Required)

Father

Mother

Stepfather

Stepmother

Grandparent

Other

How did you find out about Sunshine?(Required)

If Other, please describe(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contacts

(Contact 1) Name(Required)

First Last

(Contact 1) Relationship(Required)

(Contact 1) Phone (h/c/w)(Required)

(Contact 1) May Pick Up?(Required)

Yes

(Contact 2) Name

First Last

(Contact 2) Relationship

(Contact 2) Phone (h/c/w)

(Contact 2) May Pick Up?

Yes

Participant Background

Please check the box if there’s been any history and include an explanation for each.

History/Background

Please provide additional background for your selection(Required)

Current Medications

Reason For Taking

OTC

Dosage/Frequency

Reason for registering(Required)

Permissions

Please read through this form and initial each section (if applicable) in the appropriate areas.

I understand that the program I have registered for has limited availability and the space will be reserved for myself/my child. I understand there is a MONTHLY fee for this program, and I must let Sunshine know immediately if I have to cancel. I understand that all deposits are non-refundable.

YES

I understand there are basic behavioral rules and guidelines that must be followed by all participants and may not be a good fit for everyone. I understand some participants may need a higher level of care than this program provides. I understand if behaviors that are deemed “inappropriate or unsafe” present themselves and continue after addressing this, a parent/staff meeting will be held to decide if the program is the best fit. If the program is deemed to be “not a good fit,” additional resources will be provided.

YES

I understand this program is education and support and NOT considered counseling or therapy. I understand that this program goes along nicely with outside therapy or counseling but does NOT take the place of counseling or therapy. Sunshine may be able to provide additional resources if a participant needs a higher level of care.

YES

If you DO NOT allow the use of any pictures/videos for the center’s purposes, CHECK HERE

YES

I understand that Sunshine Center staff are mandatory reporters, and all staff follow all guidelines on confidentiality of participants & will value in high regards confidentiality of all participants. I understand that confidentiality will be broken if Sunshine Center feels that my life, my child’s life or another’s life is in jeopardy.

YES

I have read all the above information and I am aware of the guidelines/rules set forth by Sunshine.

YES

Name of participant's parent/guardian agreeing to the above permissions

Assessment Form (Optional)

Each applicant will need to complete the Assessment Form and send to Sunshine Prevention Center. OPTIONAL IF RETURNING - UPDATE AS NEEDED (DOWNLOAD FORM)

Program Fees

Please select the program that was agreed upon during Initial Family Assessment” Participants be currently in grades K - 12

Program Selection(Required)

Registration Options(Required)

Registration Fee Only ($25)

One Month Payment in Full ($125) (registration fee waived)

Three Months Payment in Full ($350) (registration fee waived)

Starting Month(Required)

Transaction Fee

Price: $0.00

(Fee to process the credit card transaction)

Total

Credit Card(Required)

Card Details

Cardholder Name

Additional Comments