Form

Form
Shine Within!

6 Week confidence and resilience program
Parent's Name

First NameLast Name
Email
example@example.com
Phone Number

Country CodeArea CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Child's Name

First NameLast Name
Additional child

First NameLast Name
Childs age blanks
🧠 What brings you to the Shine Within program?
What challenges is your child currently facing? (Tick all that apply)

Low self confidenceAnxiety or worriesDifficulty with friendshipsTrouble expressing emotionsStruggles with resilience/bouncing backOther
🎯 What would you most love to see change for your child over the 6 weeks?
💬 Why are you interested in being a beta tester?
💷 Confirm Your Commitment
- The beta testing program runs for 6 weeks starting Tuesday 22nd April 2025.
- The cost is £10 per week, paid weekly or upfront (£60 total).
- In return, you’ll receive the full program experience at a discounted rate and be asked to provide feedback at the end.
Do you agree to commit to the 6-week beta testing program

I agree
Do you understand the cost and agree to provide feedback

I agree
Should be Empty:

Shine Within!