Enroll

Please complete the form below to join LifeWorks.

*LifeWorks respects the privacy of our clients and will never share or sell any of your information to third parties.

Parent Information

* Indicates required field

Parent 1 - Name *

First

Last

Email *

Phone Number *

Parent 2 (optional) - Name *

First

Last

Email *

Phone Number *

Student Information

Student Name *

First

Last

Grade *

Student Email *

Student Phone Number *

School *

Please share anything you would like to about your child's needs. *

How did you hear about us? *

Billing Information

All payment information is securely stored. Invoices are emailed out at the end of each week.

Name *

First

Last

Email (if different than above) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Credit Card Number (VISA or Mastercard) *

Expiration Date *

* Billing takes place at the end of each week.
* We require 24 hours notice for reschedules and cancellations. (Unexpected illness and family emergencies excepted).
* If less than 24 hours notice is given a 50% fee will apply. If no notice is given the missed session will be billed at our full rate.

Agreement *

- I agree to the above terms.

Submit

Welcome!

Please complete the form below to join LifeWorks.

Parent Information

Student Information

Billing Information

Corte Madera

Mill Valley

CONTACT US

UPDATE BILLING

​Welcome!

Please complete the form below to join LifeWorks.

​Parent Information

Student Information

Billing Information

Corte Madera

Mill Valley

CONTACT US

UPDATE BILLING

Welcome!

Parent Information