Mom's name *

First Name

Last Name

Teen's name *

First Name

Last Name

Mom's Phone number *

Please note that if I can't reach you by email, I will send you a text message

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Have you been part of any of my classes, workshops, or private practice ? *

Yes!

Not yet!

*To purchase your ticket : Canada: Please send your payment via e-transfer to stephaniemankarios@gmail.com and write your full name + name of this program in the 'note' section of the e-transfer. Once I receive this form + your payment, I will email you to confirm that you're in! *

Please note that simply filling out this form does not ensure that you have a spot in the workshop!

Sending $354 for us both!

Payment plan: Sending $177 now and $177 two weeks before start date !