Get S-M-A-R-T, Jr. Registration Form
This is an initial registration form to send information to the program counselor who will contact you regarding your teen. This FREE workshop is designed for students ages 14 to 18 years old, due to the content covered. If you have more than two students you would like to sign up for this program please contact Sara Tyner at sara2@willowstone.org after you submit the form. All sessions will be held at Willowstone Family Services, 615 N. 18th Street, (Howarth Center) Suite 101, Lafayette, IN 47904. If you have questions about this program or need information regarding the requirements please contact our office at 765-423-5361, or email Sara Tyner at sara2@willowstone.org.
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Email *
Parent/Guardian First Name *
Parent/Guardian Last Name *
Youth First Name *
Youth Last Name *
2nd Youth First Name
2nd Youth Last Name
Address *
City *
Zip Code *
Parent/Guardian Phone number *
What do you hope to achieve from this program? *
How did you learn about this program *
If you answered "other" for the previous questions, please state how you heard about this program here.
Do you know a family you could recommend this program to? If so please share their contact information and we will send them details about the program.
A copy of your responses will be emailed to the address you provided.
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