Waiver - Student Registration

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Student Registration

Thank you for your interest in our program! We are so excited to work with you and your child!

We require a $25 Registration Fee per semester. Our sessions are offered virtually, in person, or hybrid and meet one to two times a week for 90 minutes. Sponsorships are available to families in need. Please email info@livelifeinsideout.org or call/text 443-379-4648 for more information.

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

Please select your availability:

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

What hours are you available?

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)

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.

Parent/Guardian Signature

Student Signature

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

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