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Lima Family Anger Management Group

Date: Every Monday, Beginning October 9^th – November 13^th, 2023

Time: 6:00-7:30PM

First Parent\Guardian Name

First Name

Last Name

Second Parent\Guardian Name (if applicable)

First Name

Last Name

First Child Name Attending

First Name

Last Name

Child's DOB

(mm/dd/yyyy)

Second Child Name Attending (if applicable)

First Name

Last Name

Child's DOB (if applicable)

(mm/dd/yyyy)

Third Child Name Attending (if applicable)

First Name

Last Name

Child's DOB (if applicable)

(mm/dd/yyyy)

Parent\Legal Guardian's Contact Information

Phone

Email

Verify Email

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Please briefly explain why you are interested in attending this group:

Registration Payment

Registration/Group Fee

*

$80 - per family