BOLD MYNDS Registration Form
Maximizing Youth's Nobility, Drive & Success
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Email *
Child's Full Name *
Parents Email *
Child's Email (If applicable)
Address *
Phone number
Emergency Contact Information – Alternate Pickup/Release
Emergency Contact
Full Name *
Phone Number *
Relationship to child *
Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).
Is your child allergic to any type of food or medication? *
If yes to the above question, please explain:
Photo Release
I hereby give permission for my child to be photographed during the BOLD MYNDS Mentorship Program in partnership with Long Island Girl Talk (LIGT). I understand the photos will be used to keep a journal of activities, to share during PowerPoint presentations and/or reports to our donors, and for promotional purposes including flyers, brochures, newspapers, and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of BOLD MYNDS and its affiliates. Please sign your name if you agree. Put N/A if you do not agree. *
Thank you in advance for supporting BOLD MYNDS’ vision of empowering our youth. We are an all-inclusive program and we want to keep our rates affordable. We have a monthly participation fee of $25.00 or $6.25 per session. We also accept bi-weekly payments of $12.50. Your support is imperative to BOLD MYNDS' growth and will enable us to continue to provide the youth with invaluable experiences. Our payment options are- Cash, Venmo: @BoldMynds and Cash App: $BoldMynds PayPal:
A copy of your responses will be emailed to the address you provided.
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