VMB Session Enrollment Form

VMB Development, Inc.

Enrollment Form For Online Sessions

Child's Full Name

Any Current Medical Diagnosis

YESNO

If Yes, Please Provide Diagnosis or If No, Why You Would Like To Have Sessions:

Current Age

Date of Birth

Date

School Currently Attending

Grade in School

Town & State Currently Living

Parents or Guardians Full Names

Marital Status

Who Does Child Live With

Phone Number

Email Address

example@example.com

Levels & Number Of Sessions Per Week

There are 8 Levels of required exercises. On average, it takes 24 weeks to complete.

The following is the recommended number of 45-minute sessions per week (Monday – Sunday) to enroll in. It is your choice in the number of sessions, 1-5, you would like to have each week:

Levels 1-4: 3 to 5 Sessions

Levels 5 & 6: 2 to 3 Sessions

Levels 7 & 8: 1 to 2 Sessions

The charge for each week of sessions is currently $100.00. If you cannot afford, adjustments can be made monthly to your weekly charge depending on donations received.

Please provide the amount per week you can afford to pay:

Please provide below the information regarding weekly sessions for you and your child:

Number of Sessions Per Week You Would Like:

(Below) - Input Days Of The Week (Mon-Sun) & Times (Your Time Zone) That You Would Like For Your 45min Sessions Each Week:*

Signature

Clear

Date