Student Registration

Thank you for your interest in our program! We are so excited to meet you! Our program starts with a four week summer fun filled program. We have fun and engaging activities lined up this summer that we know you will enjoy! This program will run into the 2022 - 2023 academic school year with two 10 week sessions (Fall and Spring) where we will offer academic support and mentorship.

We offer a virtual option and meet twice a week for two hours. We require a $25 annual commitment fee. This fee will cover the cost of materials and resources needed to successfully run the program. Should you have any questions, please email info@livelifeinsideout.org or call 443-379-4648.

Student First Name

Parent/Guardian First Name

Student Last Name

Parent/Guardian Last Name

Phone

Annual Gross Income

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Student's Grade Level

Birthday

Race

Gender

Middle/High School Currently Enrolled In

Inside Out Mentoring Program requests your permission to take photos and use them for legal purposes such as use for web content, social media content, grant applications, publicity and advertising. Please select whether or not you grant us permission to use any photos we take of your child:

I grant Inside Out Mentoring Program, Inc. permission to take photos of me during sessions and use them for advertising and grant application purposes only.

I do not grant Inside Out Mentoring Program, Inc. permission to take photos of me during sessions and use them for advertising and grant application purposes only.

Commitment to Inside Out Mentoring Program:

I agree to commit to the Inside Out Mentoring Program by regularly attending sessions and paying the annual $25 membership fee.

I agree to commit to the Inside Out Mentoring Program by regularly attending sessions, but I am unable to pay the annual $25 membership fee. Please email us at info@livelifeinsideout.org with questions or concerns about our membership fee.

How do you prefer to meet with your coach?

I prefer to meet with my coach online

I prefer to meet with my coach in person

I prefer to meet with my coach using the hybrid model (some meetings are online and some are in person)

Parent/Guardian Signature

Student Signature

Thanks for registering. We can't wait to work with you!