THE NEBH “RATIONAL”TEEN PROGRAM

 

The Just for Teens – Rational Living Skills Program

 

 

REGISTRATION

 

 (PLEASE CALL NEBH AT 860-659-6551 FOR CHILD’S EVALUATION ONCE REGISTERED)

 

Please mail check for $720.00 to NEBH 2389 Main Street Glastonbury CT, 06033. Once registration has been completed and evaluation phone call has been made to NEBH.  Make all checks payable to NEBH

Teenagers Name
Age
Grade
School System
Name of Parent
Name of 2nd Parent ( If Applicable )
Street Address
Street Address Cont.
City
State
Zip Code
Daytime Phone
Evening Phone
Cell Phone
Email Address
Reason For Participation
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