2022 Summer Circles Program Registration

Summer Circles Program

REGISTRATION FORM
Welcome to the online registration for
Summer Circles with Serenity-BHS!

The goal of our Summer Circles Program is to create a positive and therapeutic environment for students to build self-esteem, confidence, healthy coping skills, emotional regulation, and to promote healthy peer relationships. Students will participate in crafts, outdoor activities, and group discussions that focus on the social and emotional wellness of the student. This program gives students the opportunity to stay connected with their peers and Serenity-BHS therapists throughout the summer.

The Summer Circles Program will take place at the Serenity-BHS Wellness Center in Westerville, Ohio. The Wellness Center offers a spacious indoor area where students can explore, an outdoor walking path, and other outdoor areas for games and team-building activities.

This program is FREE to Cornerstone Academy students, therefore space is LIMITED. Please do not sign up your student if you do not know for sure that they can attend, as this will take away a spot from another student who can attend. it is VERY important that you communicate with Serenity-BHS staff if you are unable to fulfill your spot so we can give it to another student. Please contact Linda@serenity-bhs.org if your child is no longer able to attend.

Groups will start May 31, 2022 and continue through July 28, 2022.

2022 SCHEDULE

Mondays

4th - 5th grade: 8:30am - 12 noon

Tuesdays

Kindergarten - 1st grade: 8:30am to 12 noon
High School Students: 1:00pm to 4:00pm

Wednesdays

2nd - 3rd grade: 8:30am - 12 noon
2nd - 3rd grade: 1:00pm - 4:00pm

Thursdays

6th grade: 8:30 - 12 noon

**Grades are based off of 2020-2021 school year**

Wellness Center address:

635 Park Meadows Rd., Suite 107
Westerville, OH 43081

IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT

Linda Strapp, LISW-S
linda@serenity-bhs.org
Student Information
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade*
Gender*

MaleFemaleOther
Sexual Orientation:*

StraightGayLesbianNon-BinaryOther
Race:*
Parent/Guardian Information
Parent Name*

First NameLast Name
Parent Cell Number*
Parent E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Secondary Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Presenting concern:*
Describe your concerns:*
Describe your current intervention effectiveness and results:*
Summary of parent contact/involvement:*
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent/Guardian Signature *

Clear
Date*

MonthDayYear
Date
Serenity-BHS Staff will contact you to confirm your registration due to spots being limited.
Should be Empty:

Summer Circles Program

2022 SCHEDULE

**Grades are based off of 2020-2021 school year**

Grades are based off of 2020-2021 school year