Brain-Body Emotional Regulation - GROW Group Program Registration Form
Led by Emily Hamblin & Team | Enlightening Motherhood, LLC
Section 1: Parent & Child Information
Parent/Guardian Full Name
*
First Name
Last Name
Parent E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child/Student Full Name
*
First Name
Last Name
Child's Preferred Name
*
Child's Gender
*
Child's Age
*
Child's Birth Date
*
Please select a month
January
February
March
April
May
June
July
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September
October
November
December
Month
Please select a day
1
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Day
Please select a year
2026
2025
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2023
2022
2021
2020
2019
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2015
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2012
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Year
Does your child have a formal diagnosis? (optional – not required)
Optional - anything you'd like me to know about your child?
Section 2: Program Participation
Why do you believe this program would be helpful to your child?
*
Why do you believe this program would be helpful to your child?
*
What would an ideal outcome be?
*
Anything you’d like us to know about your child’s learning style, sensitivities, or needs? (optional but helpful)
Section 3: Recording & Replay Consent
We're heading into those "legally required" sections. ;)
All classes are offered in live Zoom calls. The Zoom calls will be recorded, edited (to delete, blur, or otherwise make children's names, voices & videos unknown). These edited calls of our LIVE classes will be made available to all program participants. With that in mind - what permissions do you give for your child during these calls?
*
I give FULL permission for my child to be FULLY included in recordings (voice, image, first name, visible background).
I give PARTIAL permission (choose all that apply below):
I do NOT give permission for my child to be recorded in any form. I understand that it is my responsibility to ensure that my child’s video and mic are kept off during the entire class.
If you give PARTIAL permission, what type of permission do you give for your child?
Child’s first name
Child’s voice
Child's video image
Visible background
Other individuals in household
Parent/Guardian Responsibility if Opting Out
If you do not grant full permission, the following becomes that parent/guardian's responsibility
Enlightening Motherhood LLC & its instructors/coaches are not responsible for enforcing these requirements or preventing accidental disclosure if you opt out. Responsibility rests solely with the parent/guardian.
*
Yes, I agree to be responsible for my child's video/mic/background usage during Zoom calls
No, I disagree and will not allow my child to participate in the live class.
Section 4: Agreement & Policies (Legally Required)
Section 4: Agreement & Policies (Legally Required)
*
Section 5: Final Consent & Signature
By checking the box and signing below, I confirm that:
Do you agree to all the terms and conditions as outlined on this form?
*
Yes, I agree to all terms listed above and consent to enroll my child.
No, I do not agree and will not enroll my child.
Signature
*
Full Written Name of Signature
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Optional - anything else you'd like our team to know?
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