Program Registration Form

To register for an upcoming course or program, please complete the form below.

UPCOMING COURSES & PROGRAMS

Future Builder Workshop Series
(Grades 9-12)

Mondays beginning June 1st
6:00pm - 7:00pm

The Future Builder Workshop Series is a 10-week experience designed to support teens in discovering who they are and where they’re headed. Through guided conversations and practical tools, students build confidence, improve decision-making, and gain clarity about life after high school. This program creates a safe, supportive space for students to grow, reflect, and step into their future with purpose.

* REGISTRATION ENDS MAY 26TH *

CONTACT INFORMATION
Participant's Information

TEEN'S Full Name

First NameLast Name

Age

Grade Level

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

School Name

Email Address

example@example.com

ADDITIONAL PARTICIPANTS

If you have more than one teen who will be attending, please provide their information below.

Do you have another teen attending? Yes or No

TEEN'S Full Name

First NameLast Name

Age

Grade Level

School Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

CONTACT INFORMATION
Parent/Guardian's Information

PARENT/GUARDIAN'S Full Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Relationship to Participant(s)?

MEDICAL INFORMATION

Does your teen have any known allergies?

If yes, list them below.

Type 'N/A' if there are no allergies.

Please include any other medical notes regarding your teen.

Type 'N/A' if there are no medical notes.

EMERGENCY CONTACT & PICK-UP AUTHORIZATION

Emergency Contact Name

First NameLast Name

Emergency Contact Phone #

Please enter a valid phone number.Format: (000) 000-0000.

PICK-UP AUTHORIZATION The following person is authorized for pickup:

Please include their relationship to your teen.

MEDIA CONSENT & RELEASE

I give permission for NiQ Life Coaching to take and use photos or videos of my child for promotional or educational purposes (such as social media, website, or newsletters).

I understand that I will not receive any monetary compensation for the use of these images.

I grant NiQ Life Coaching the right to edit, publish, or distribute these photos for any lawful purpose.

I understand I can revoke this consent at any time by providing written notice to the program facilitator.

PROGRAM AGREEMENT
Future Builder Workshop Series
____________________________________________________________

Program Duration
This program will run for a total of 10 weeks. Each session is designed to build upon the previous week, creating a structured and progressive learning experience for all participants.

Days/Times
Sessions will take place weekly on Mondays at 6:00 PM. Each session will last approximately one hour. Participants are expected to arrive on time to ensure they receive the full benefit of each session.

Payment Terms
Full payment is required prior to the start of the program in order to secure enrollment. A participant’s spot is not guaranteed until payment has been received in full.

Attendance Expectations
Consistent attendance is strongly encouraged, as each session builds on the previous one. Participants are expected to arrive on time and ready to engage.

If a participant is unable to attend a session, a parent/guardian should notify in advance via email or text. While sessions are not repeated, support will be available. The facilitator will be available up to 15 minutes before each session for brief check-ins or questions related to missed material. Additional questions may also be submitted via email.

No Refund Policy
Due to the limited number of available spots and the structured nature of the program, all payments are non-refundable once the program has begun.

Behavior Expectations
Participants are expected to:

~ Be respectful to the facilitator and other participants
~ Actively participate and engage in activities and discussions
~ Limit distractions, including cell phone use during sessions
~ Contribute to a positive, focused, and supportive environment

Failure to meet these expectations may result in removal from the program without a refund.

Liability Waiver
By enrolling in this program, the parent/guardian acknowledges and agrees that participation is voluntary. The facilitator and hosting facility are not responsible for any injuries, losses, or damages that may occur during participation. Parent/guardian consent is required for participation.

Acknowledgment
I, the undersigned parent/guardian, acknowledge that I have read and understand the terms and expectations outlined in this agreement for the Future Builder Workshop Series. I agree to the program policies, including payment terms, attendance expectations, behavior guidelines, and the no refund policy.

I understand that my child is expected to actively participate, remain respectful, and follow all program guidelines. I also acknowledge the liability waiver and give permission for my child to participate in this program.

Parent/Guardian's Signature

Date

Participant's Signature

Date

2nd Participant's Signature

Date

PAYMENT

Future Builder Workshop Series
____________________________________

10-Week Workshop Fee:
$149 per teen
$199 for 2 teens

*Includes one workbook per teen

This is a one-time fee covering all 10 sessions.

Signature

Date

How did you hear about us?

Please send your questions or concerns to taniqua@coachniqspeaks.com.

Please make sure selection below.

Future Builder Series - Single Registration

1 Teen - Grades Levels 9-12

$149.00 Quantity

Future Builder Series - Group Registration

2 Teens - Grade Levels 9-12

$199.00 Quantity

Total

Payment Methods

Debit or Credit Card

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