New Buds Application Form - The Help Group

Child's Name(Required)

First Middle Last Nickname

Date of Birth(Required)

Age(Required)

Gender(Required)

Male

Female

Non-binary

Has this child ever participated in THG activities/schools?(Required)

Yes

No

If YES, please name school and/or program(Required)

Parent/Guardian's Name(Required)

First Last

Email(Required)

Mobile Phone(Required)

Home Phone

Does your child have any specific diagnoses?(Required)

Yes

No

If YES, please list each diagnosis and when your child was diagnosed?(Required)

Will you require a payment plan?(Required)

Yes

No