The Girls' Connection Application | Lori Stephens, LLC

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941-345-7574

Application for The Girls' Connection

Student First name*

Student Last name*

Email

Phone

Nickname

Address*

Birthday

Month

Day

Year

Allergies

Please list any diagnosis and/or learning disabilities/challenges so we may better serve your student.

Student Strengths:

Please tell us any areas of need your student may have or any information you would like us to know:

Emergency Contact Information #1- Name: Phone: Relation:*

Emergency Contact Information #2- Name: Phone: Relation:

Parent/Guardian Name*

Address*

Phone*

Email*

Parent/Guardian Name

Address

Phone

Email

Single choice

$100 per month paid annualy

$105 per month paid quarterly

$110 per month paid monthly

Contact

Powerful Education Solutions, LLC

63 Sarasota Center Blvd #107

Sarasota, FL 34240

office@loristephensllc.com

Phone: (941) 345-7574

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