480-668-8301
1745 S. Alma School Rd Suite 230
Mesa, AZ 85210
  Toll Free: 1-800-614-8142

Band of Brothers Registration

Participants and a parent must first meet with a Band of Brothers therapist to do a counseling session, for an assessment of appropriateness for the program.

Youth Details
PLEASE DO NOT ENROLL FROM A MOBILE DEVICE. REGISTRATIONS PERFORMED VIA MOBILE DEVICES OFTEN DO NOT PROCESS COMPLETELY.
   
First Name :
Last Name :
Youth Date of Birth :
Youth Grade in School :
Name of School Youth Attends :
Youth's Mobile Number :
 
Parent Details
First Name :
Last Name :
Parent Email Address :
Parent Phone Number :
 
Do you have Blue Cross Blue Shield Insurance? :
If yes:    
Member ID Number: :
Group Number: :
Primary Insured Full Name: :
Primary Insured Date of Birth: :
     
Emergency Contact Details
First Name :
Last Name :
Emergency Contact Phone Number :