Mindful Adventure Program Registration
Please fill out all information so that we can better take care of your children. These programs are open to youth in Orange County and surrounding areas on: Every Saturday at Bodhi Academy Afterschool Center.
Email address *
PARENT AND/OR GUARDIAN INFORMATION
First Name (1) *
Your answer
Last Name (1) *
Your answer
Select Your Relationship: *
First Name (2)
Your answer
Last Name (2)
Your answer
Select Relationship:
Mailing Address *
Please provide full address (number, street, city, state, zip code)
Your answer
Home Phone *
Your answer
Cell Phone *
Your answer
Email Address *
Your answer
First Emergency Contact Info: *
Name, Relationship, Cellphone for the person we can contact for emergency while your children are attending BYA activities
Your answer
Second Emergency Contact Info: *
Name, Relationship, Cellphone for the person we can contact for emergency while your children are attending BYA activities
Your answer
Family Doctor:
Name and Phone of your children's doctor in case we cannot reach you in case of medical emergency
Your answer
YOUTH MEMBER INFORMATION
Youth First Name (1) *
Your answer
Youth Last Name (1) *
Your answer
Age (1) *
Your answer
Gender (1) *
Select your preferred Group (1) *
Register only to Specialty Session (1) *
Required
Has your child been introduced to the mindfulness practice? *
Ethnic Background (1)
Youth's Email Address (1)
Your answer
School Attending (1)
Name, City, or District
Your answer
YOUTH MEDICAL INFORMATION
Youth Full Name (1) *
Your answer
Date of Birth (1) *
Your answer
Medical Condition (1): *
Please list any medical condition we should be aware of
Your answer
Specific Instruction or Activities not to be engaged (1): *
Your answer
Allergies or Reactions (1): *
Please list any food and/or medicine allergies or reactions
Your answer
Would you like to register for another youth? *
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