Enrollment Form Name * Parent's Name First Name Last Name Email * Address * Where to ship your care package Address 1 Address 2 City State/Province Zip/Postal Code Country Teen's Name Teen's Age What specifically do you hope your teen will learn from Positively Healthy U? Do you have any special concerns about your teen? Is there any else you'd like to share about your family? Are you referring another family to Positively Healthy U, or were you referred by someone else? * No (I’m not referring anyone, nor was I referred) Yes—I’m referring another family Yes—I was referred by another family I understand my $150 deposit secures my spot. The remaining balance ($447) is due two weeks before the program begins. (Deposit invoice will be emailed within 24 hours.) Yes I understand that if my referred family (or the family who referred me) also completes enrollment, I’ll receive a $50 discount on my final invoice. Yes No referral Thank you! If you have any additional questions, my email is: laura@positivelyhealthycoaching.comIf you prefer a conversation, use the blue button to the right that says “Schedule a free call” and choose Positively Healthy U - 10 minute call.
