Back 2 The Basics: Virtual Youth Empowerment & Enrichment Program for Girls (Ages 12

How did you hear about this program?*

Youth Name*

First NameLast Name

Age*

Date of Birth*

Date

Gender*

Participant's Phone Number

Please enter a valid phone number.

Participant's Email Address*

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

School*

Grade Level*

Expected Graduation Year*

Student's Hobbies*

i.e. sports, music, poetry, video games, etc.

What do you hope your child gains from this mentoring program?*

How would you describe your child’s personality?*

What are your child’s biggest strengths?*

What challenges does your child face at school, socially, or emotionally?*

Do you have any concerns or questions you'd like to discuss before the program begins?*

Does your child have access to a computer and reliable internet connection to participate in this program?*

YesNo

Does your child have any allergies, medical conditions, or special needs we should be aware of?*

Parent/Guardian's Name

First NameLast Name

Parent/Guardian's Phone Number

Please enter a valid phone number.

Relationship To Participant

Payment Method

By checking the following boxes and signing this form, I agree:

By enrolling in the program, you give permission for your child to be photographed or recorded during sessions or events for promotional, educational, and social media purposes, unless otherwise noted on your registration form.Participants are expected to follow rules of respect, cooperation, and safety. Repeated disruptive, unsafe, or disrespectful behavior may result in temporary or permanent dismissal from the program at the discretion of program leadership."Back to the Basics" does not provide transportation services unless otherwise specified. Parents/guardians are responsible for ensuring safe and timely arrival and departure from all program activities.This program is not a substitute for medical, psychological, or therapeutic services. If your child requires professional care, please consult with a licensed healthcare provider. Staff and mentors are not licensed clinicians and will not administer medication or provide medical care.The "Back to the Basics" Youth Mentoring Program is designed to provide guidance, education, and positive mentorship. While we aim to offer a safe and encouraging environment, participation in the program does not guarantee specific outcomes. Parents and guardians remain ultimately responsible for the well-being and supervision of their child outside program hours.While mentors will respect the privacy of participants, confidentiality cannot be guaranteed in cases where there is a concern for the safety or well-being of the youth or others. In such cases, appropriate authorities may be notified.

Parent/Guardian Signature

Date Signed

Date

My Products

Back 2 Basics Youth Mentoring Program DepositTotal investment is $1000. Coach K is offering mentoring program package at $350. Final payment of $175 due before the first session. This includes digital workbook, Back 2 Basics T-shirt, and Certificate of Completion. All payments are non-refundable.

$175.00

Total

$0.00

Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info

Back 2 The Basics: Virtual Youth Empowerment & Enrichment Program for Girls (Ages 12–17)

Empowering young girls to lead, grow, and thrive—one session at a time.

Ready to invest in the next generation of confident, purpose-driven young women?

Parent/Guardian Information

Payment Details

Back 2 The Basics Agreement