MOVE Application

Please respond to every question before submitting this form.

This session is for ages 11-17, the MOVE program is designed to develop a habit of mindfulness in youth and improve their emotional intelligence. Immersed in sensory play, sessions are anchored around movement therapy theory, exploratory dance, mindfulness, and trauma informed practices to increase healthy socioemotional development. The program is centered on the idea that building the practice of moving the body is central to healing, helping young people regain a sense of physical & emotional self while promoting resilience.

Student Name*

First NameMiddle NameLast Name

Birth Date*

MonthDayYear

Gender Pronouns:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Student's School*

What is the Student's Grade?*

What is the Student's GPA?*

Parent's Email, If none, please type n/a*

example@example.com

Student E-mail, If none, please type n/a*

example@example.com

Parent's Mobile Number*

Area CodePhone Number

Student's Phone Number

Area CodePhone Number

THIS IS NOT A DANCE PROGRAM. If, you child enjoys dance, they can tryout for our free CORE Dance Team. ALL CORE team members are required to be enrolled in MOVE. Does your son/daughter have experience in one or more of the following?*

Please List Any known Allergies or Health Concerns:*

Is there any reason this child should not engage in physical exercise? If so, please include a permission letter and identify all physical limitations from the physician clearing them to participate.*

YesNoOther

Practicing coping skills is important. Describe one or two goals you have for your child during this 24 week period.*

Please describe any behavioral challenges or concerns. If none, write n/a. *

Just Speak staff and volunteers will not administer any medication. Your child must be responsible for taking prescription and OTC medication. Just Speak, nor its affiliates will be held responsible for any medical emergencies or accidental injuries to your child. In submitting this application, you agree not to hold Just Speak liable.

Youth are expected to exhibit appropriate behavior. We provide a safe space to learn, grow, and move in an atmosphere of respect. We do not tolerate bullying, offensive language, fighting, or disrespect. We make every effort to modify disruptive behavior and keep the child in our program. However, continued disruption could result in removal.

Submitting the application and the digital signature entered below, indicates that you are in agreement with the above terms.

I understand the terms of this application and accept as the parent and legal guardian*

First NameLast Name

Photo Release and Waiver:

I hereby grant Just Speak permission to use my child's likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.

I hereby irrevocably authorize Just Speak to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge Just Speak Inc. from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW. I ACCEPT:

I Accept the terms of the photo release and waiver*

Your Signature Confirms that all state is true and that you are the Legal Parent or Guardian*

First NameLast Name