PEERS - Teen Connect Fall 2026
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Current:
Registrant
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Billing
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Participant Information
First Name:
Last Name:
Preferred Email:
Email
Confirm
Your password must have
each of the above components
and be at least 12 characters.
Does Not Pass
Low
Moderate
Secure
Very Secure
Re-type your password.
Re-type your email.
Please verify your input by typing it again.
Passwords do not match!
Emails do not match!
Inputs do not match!
Passwords match!
Emails match!
Inputs match!
Birth Date:
RadDatePicker
RadDatePicker
Open the calendar popup.
Calendar
Title and navigation
Title and navigation
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September 2026
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Please select the date between 1/1/1900 and 12/31/2099
Cell Phone Number:
Participant Pronouns:
Parent Information
Parent First:
Parent Last:
Email:
Email
Confirm
Your password must have
each of the above components
and be at least 12 characters.
Does Not Pass
Low
Moderate
Secure
Very Secure
Re-type your password.
Re-type your email.
Please verify your input by typing it again.
Passwords do not match!
Emails do not match!
Inputs do not match!
Passwords match!
Emails match!
Inputs match!
Cell Phone Number:
Emergency Contact Name:
Emergency Contact Phone Number:
Intake Information
Please list all allergies, medications, medical concerns, and/or other health issues. If not applicable, please answer N/A.
Please upload the participant's most recent IEP:
Please upload your most recent psychoeducational evaluation:
How did you hear about this program?
Please Choose
Kinney Center Website
SJU/Kinney Events Calendar Listing
Word of Mouth/Referral
Email
Web Search
Flyer
School Counselor/Therapist
Other
In order to participate in this program, the participant will need to complete a thorough intake process with our program staff. If a participant is found to be ineligible for participation, a refund will be issued.
Please check here to agree to this statement:
Please check here to agree to this statement:
I Agree
Payment
Amount:
Please Choose...
$1,500.00 - PEERS - Teen Connect
Promo Code (if applicable):
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