BOLD MYNDS Registration Form
Maximizing Youth's Nobility, Drive & Success
Sign in to Google to save your progress. Learn more
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 Nassau Community College. 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. *
TUITION INFORMATION
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 $35.00 or $8.75 per session.  We also accept bi-weekly payments of $17.50.  Yearly Rate: $350.00- regular price is $420.00 (you get a 20% off discount if you pay for the entire year upfront and every trip presented is free for the year, including meals during trips).

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: Bold@Boldmynds.com
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Soledad Maurice Innovaions. Report Abuse
Google Forms