The B Positive Movement Intake Form
Thank You for your interest in enrolling your child in The B Positive Movement Inc. Our mission is "To encourage a Positive perspective amongst our youth in hopes of maximizing their fullest potential." 
Please complete this form to help us better understand your child's needs and how we can best support their growth. 
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Parent/Guardian Information 
Parent/ Guardian Full Name: 
Relationship to the Child:
Phone Number:
Home Address:
Email Address:
Child Information 
Child's Full Name: 
Date of Birth: 
Age: 
School Name: 
Grade: 
Program Interests & Areas of Growth 
Please describe what you would like The B Positive Movement to focus on with your child (check all that apply)
Additional Questions: 
What are your child's strength's? 
What challenges is your child currently facing?
Are there any behavioral, emotional or academic concerns that we should be aware of? 
Consent & Acknowledgment 
I give permission for my child to participate in The B Positive Movement mentoring program. I understand that this program is designed to support personal growth, mentorship, and positive development. I acknowledge that participation is voluntary. I, my heirs, successors, executors and subrogess, hereby knowing and intentionally waive and release indemnify and hold harmless The B Positive Movement Inc. it owners, board, sponsors, employees, and volunteers from and against any and all claims, actions, causes of actions, liabilities, suits, expenses ( including attorney's fees) which are related to, arise out of, or are in anyway connected to my participation in the program. 
Parent/Guardian Signature:  *
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