NCO -ACES Registration

ACES Registration

Please complete the form below to register for the ACES classes. $109 if registered/paid by 1/18/2012, $129 after 1/18/2012. * All Fields are Required
Name of Youth:
Age:
School :
Grade:	4 5
Register for:	Boys - starting Jan 26, 2012 Girls - starting Jan 25, 2012
Name of Parent or Guardian:
Address:
City:	State:
Zip Code:
Phone:
Parent E-mail:
Emergency Contact:	Phone:
Please list any current medications and medical conditions that we need to be aware of (including food allergies)*
In order to make the group as effective as possible, it would be helpful for us to know what challenges your child may be facing (i.e. bullying, learning how to approach people to start friendships, handling difficult emotions, etc). Please briefly list any of these issues. *
Additionally, are there any other areas of concern that would good for us to know (such as parents divorcing, grief or loss issues, etc)? *
* Please note that you may call to note any issues if you are more comfortable with that option - simply note that in the comment boxes above. Contact Kari Wittman Lata at (630) 717-9408 x112 or email kwlata@360youthservices.org
Payment Method:	Credit Card/Paypal (link provided on confirmation page) I'll mail a check I would like more information on financial assistance Other