Workshop Registration

* Indicates required field

Participant Name *

First

Last

Participant Age *

Participant Grade *

Participant School District *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Parent/Guardian Email *

Parent/Guardian Phone Number *

Parent/Guardian Relationship *

Emergency Contact Name *

Emergency Contact Phone Number *

Program Confirmation *

I confirm that I am registering the above-named child for the Healing Pages Journaling Workshop which will be held at the NSYC Rec Room, located in the portable building on the grounds of the Joseph A. Edgar School in Rocky Point, on Saturday, November 2nd from 1:00-2:30PM. The cost of the program is $50 per child.

Photo Permission *

Yes, I DO give permission for my child's photo to be taken and to be used for marketing, advertising, and/or fundraising purposes, electronically or otherwise. No, I DO NOT give permission for my child's photo to be taken and to be used for marketing, advertising, and/or fundraising purposes, electronically or otherwise.

Please review our workshop policies and procedures. By signing this document below, I acknowledge that I have read, understood, and agree to adhere to the workshop procedures and policies outlined above. I give permission for my child to participate in the workshop and accept the terms as stated. I understand that this registration is not complete until submitted and payment is completed.

Electronic Signature *

Today's Date *

I agree to receiving marketing and promotional materials

Submit

After submitting the above registration form, please complete payment by following the steps below:

Workshop Registration Fee: Healing Pages Journaling 11/2/24

$50.00

Registration fee for the Healing Pages Journaling Workshop on 11/2/24.

Add to cart

North Shore Youth Council is a 501(c)(3) not-for-profit community-based organization, funded in part by the Town of Brookhaven, the County of Suffolk, the State of New York, the North Shore Consortium, and public and private donations.

Phone: 631-744-0207

Fax: 631-744-3565

P.O. Box 1286, Rocky Point, NY 11778

Main Office Hours: Mon-Fri, 9am to 5pm

Visit us in the portables on the grounds of the
Joseph A. Edgar School in Rocky Point.