Group/Family Education Registration Form

Group/Family Education Registration Form
Name*

First NameLast Name
Email*
example@example.com
Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group*
Committment*

I understand I am committing to ALL sessions.
Payment Details

After you register, please return to our website to subscribe to your group. You will be charged a weekly fee for group/education sessions. This fee is charged regardless of attendance as commitment to all group sessions are expected.
Reminders
Cancellation - Registrations can be canceled within 5 days before the start of the event.

Payment - Only paid registrations be accepted in the online event. Google Meet links will not be sent to unpaid registrants. In person, will require a COVID screening form. Your clinician will send it to you prior to the session. These must be completed prior to EACH session.

Payment Method - You will be charged weekly for your group OR can choose to pay in full. If paying in full, please email us for a custom payment link. Once you submit this form, please return to our website to pay for your group subscription: https://www.insightmaryland.com/groups
Signature *

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Should be Empty:

Payment Details