Teen Mindfulness Mentoring Program Waiver of Liability and Consent Form

Please fill out and submit the following form at least 24 hours prior to our session.

Program Dates:

Participant (Teen) Information:

First Name

LastName

Date of Birth

Month

Day

Year

Address

Phone Number

eMail:

Parent/Guardian Information:

First Name

LastName

Relationship to Participant

Address (if different)

Phone / Cell Number

eMail:

1. Program Description: I understand that the Teen Mindfulness Mentoring Program (the “Program”) involves guided meditation, breathing techniques, journaling exercises, group discussions, and other mindfulness activities designed to improve focus, emotional resilience, and stress reduction.

2. Voluntary Participation & Assumption of Risk: I acknowledge that participation in mindfulness activities is voluntary and may involve physical, mental, or emotional risks, including but not limited to:

Muscle tension or soreness
*Temporary emotional discomfort or stress - *We will be discussing topics, such as peer pressure, unkind comments and other things that may trigger anger and sadness.
Dizziness or lightheadedness
Unforeseen physical or psychological reactions I certify that my child is in good physical and mental health and that I assume full responsibility for any risks or injuries sustained as a result of participation.

3. Medical Information & Authorization:

Please list any medical conditions, allergies, or medications of which the instructors should be aware:

4. Emergency Contact:

Name

Relationship

Phone

Alternate Phone

5. Release and Waiver of Liability: In consideration of my child's participation, I hereby release, waive, and discharge Sage Connections (and its owners, employees, volunteers, and instructors) from any and all liability for injury, loss, or damage to person or property arising out of or related to the Program, whether caused by negligence or otherwise.

6. Photographic/Video Release: I grant permission for photographs and video recordings of my child made during the Program to be used for promotional, educational, or other purposes by Sage Connections without compensation or further authorization. All photos and videos will be sent to parents and group before release to anyone outside of the group.

7. Confidentiality: I agree that all personal information shared in group discussions or mentoring sessions will be treated with respect and confidentiality by participants and Program staff.

Acknowledgment and Consent

I have read and understand this waiver and release...

Participant Signature (if age 11 or older):

Signature field is empty.

Date

Month

Day

Year

I have read and understand this waiver and release...

Printed Name of Parent/Guardian

Parent/Guardian Name:

Signature field is empty.

Date

Month

Day

Year

I have read and understand this waiver and release...

Additional Participant Signature:

Signature field is empty.

Date

Month

Day

Year

I understand that mentoring/coaching is not therapy or a medical treatment and that it is not a replacement or substitute for professional advice by legal, mental, medical or any other qualified professionals. I understand that coaching/mentoring will not be diagnosing or treating any medical or psychological condition. This form is an agreement for services that lays out the coaching package I have agreed upon, with the time frame and amounts for payment and what coaching services will be provided in return. is a self-awareness transformative life coaching program that inspires and supports clients through self-empowerment, realizing their potential through personal achievement, and improving the quality of their life through service to others.