Middle School Confidence Starter Enrollment

1
Full Name
First Name
Last Name
2
Email Address
example@example.com
3
Phone Number
Please enter a valid phone number.
4
Relationship to the Student
5
Student’s Full Name
First Name
Last Name
6
Preferred Name
7
Age
8
Grade Level
Please Select
Please Select
5th Grade
6th Grade
7th Grade
8th Grade
Other
9
Time Zone
Please Select
Please Select
Pacific Time (PT)
Mountain Time (MT)
Central Time (CT)
Eastern Time (ET)
Other
10
Where would your child like more confidence?
Talking with teachers
Meeting new people
Connecting with other students
Speaking with family members
Asking questions or asking for help
Sharing ideas and telling stories
Other
11
What would you like your child to gain from these sessions?
12
What interests or activities does your child enjoy?
13
Is there anything Jackie should know to help your child feel comfortable and supported?
14
Email used for payment (if different from parent’s email)
example@example.com
15
I confirm that I am the student’s parent or legal guardian and give permission for my child to participate in the Middle School Confidence Starter coaching sessions through Zoom.
I confirm and give permission
16
Parent or Guardian’s Full Name (Typed Signature)
First Name
Last Name
17
Submission Date
Date
Month
Day
Year
18
Submission ID
Should be Empty: