Confidence Building Course for Middle and High School Students 4539 Metropolitan Court Frederick, MD

Goal Setting Course for Middle and High School Students 4539 Metropolitan Court Frederick, MD

May 12th - June 2nd, 2025 - 6:00pm - 7:30pm Pizza and Soda Provided
Student's Name

First NameMiddle NameLast Name
Student's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student's Date of Birth

MonthDayYear
What School does the Student Attend?
Parent/Guardian Name

First NameLast Name
Parent / Guardian Email
example@example.com
Parent / Guardian Phone
Please enter a valid phone number.
Permission & Agreement

I agree and give my permission
What is the Student's Ethnicity
How do you think this program will help/benefit this student?
What would you like us to know about the student?
Food will be provided during each session. Please note if your youth has any food allergies or Medical Concerns:
Waiver of Liability I hereby give permission for my child to participate in this class. I understand staff and volunteers will supervise the programs. If a serious illness or injury develops and medical and/or hospital attention is necessary, I give permission for emergency treatments or surgery as recommended by an attending physician. I specifically release and discharge, in advance, Living Well Youth Works, its directors, employees, and volunteers from any and all liability, whether known or unknown. I agree to accept responsibility for the risks that may occur. I hereby agree to waive, release and discharge any and all claims for damages, for death, personal injury or property damage which my child may have or which may hereafter accrue as a result of my child’s participation in this program against their person or entity whether such injury or damage was foreseeable. This acknowledgement of and assumption of risk and release shall be binding upon heirs and assigns.

I agree
Photo Release: I understand that Living Well Youth Works may take photographs or videos of programs and activities in which my child is participating. I give permission for Living Well Youth Works to use photographs or videos of my child for the purpose of promoting its services/programs in print or electronically.*

I consent
Phone Number Of Person To Contact In Case Of Emergency
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Please verify that you are human*
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Goal Setting Course for Middle and High School Students
$115.00 Quantity

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Goal Setting Course for Middle and High School Students 4539 Metropolitan Court Frederick, MD