Healthy Gaming Support Group (Mon @ 6p)

HEALTHY GAMING SUPPORT GROUP

Mondays @ 6:00 PM
Have you participated in a Richstone class or program before?

Yes No
If this is your first class, you must call (310) 970-1921 to get the additional forms needed to complete your registration.

New students will not be admitted into class if all registration and consent forms have not been submitted.
Name *

First Name Last Name
Email Address *
example@example.com
Cell Phone Number

Area Code Phone Number
Verify Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
For the safety and privacy of all tele-group and class participants, please carefully read and agree to the following guidelines. Violation of these guidelines will result in immediate removal from the tele-group.

No driving or traveling during a tele-group session. Participants must stay in one location for the duration of the tele-group.
I agree and understand (initial) *

Estoy de acuerdo y entiendo (inicial) Clear
No drinking alcoholic beverages or consumption of cannabis or taking drugs during a tele-group session.
I agree and understand (initial) *

Estoy de acuerdo y entiendo (inicial) Clear
No recording or taking screen shots.
I agree and understand (initial) *

Estoy de acuerdo y entiendo (inicial) Clear
I understand that I will need to verify that I am in a confidential location at the start of each tele-group session.
I agree and understand (initial) *

Estoy de acuerdo y entiendo (inicial) Clear
I understand and confirm that there are no other children or adults in the room with me during the tele-group session. (Headsets are recommended)
I agree and understand (initial) *

Estoy de acuerdo y entiendo (inicial) Clear
I understand that the group/class will be closed 5 minutes after the start time. I agree to be on time.
I agree and understand (initial) *

Estoy de acuerdo y entiendo (inicial) Clear
Upon completion of this course I will be sent a link via email to complete a satisfaction survey.
I agree and understand (initial) *

Estoy de acuerdo y entiendo (inicial) Clear
Signature/Firma *

Clear
Date *

Month Day Year
Date
- A copy of your registration will be automatically sent to the instructor -
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