Southeast Parent Workshop Registration

Atlanta, Georgia—December 10, 2011

Date: Saturday, December 10, 2011
Time: 10:00 a.m. to 4:00 p.m.
Location: Renaissance Atlanta Midtown (formerly the Hotel Palomar)
Address: 866 W. Peachtree Street, NW · Atlanta, Georgia 30308

Your Name(s)

Your email:

Your Child's Full Name

Your Child's Birth Date

Is your child currently enrolled at Second Nature?

Approximate dates/year of attendance:

Second Nature Program your child is currently attending or did attend:

• Second Nature Cascades
• Second Nature Blue Ridge
• Second Nature Footsteps
• Second Nature Entrada
• Second Nature Entrada/Adults
• Second Nature Uintas
• Second Nature 360

Your child’s Second Nature Therapist:

After Second Nature, your child:

• Returned home
• Attended aftercare program
• Other

Please enter the aftercare program or explain "Other".

Number attending workshop:

Please share with us what you hope to gain by attending the workshop:

*PLEASE NOTE

This is a free workshop! We will break for lunch at noon. Cost of lunch is not included but will be offered in the hotel’s café.

Questions? Please contact: familyservices@snwp.com

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