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Mindful Moments LLC Consent Form

Medical Details: Do we need to know about any medical conditions or allergies?

Permission for Medical Treatment: In the event of an emergency in which the parent/guardian cannot be contacted, Mindful Moments LLC trainers/facilitators may take appropriate action as needed.


Description of Services: Even though the trainers/facilitators/presenters may be professional counselors, Mindful Moments LLC workshops does not provide counseling but is an educational and support program designed to teach skills, facilitate self-awareness and confidence, promote new behaviors, and demonstrate how to effectively deal with some of life challenges.  


Confidentiality: Parents and outside observers will not be allowed to attend workshops, unless invited to do so by the trainer/facilitator. Participation in the sessions is completely voluntary and confidentiality is addressed and respected. This means that each participant agrees not to share any other participants identifying and personal information with others. It is appropriate to share your personal reaction and feelings about group with others, but please do not share other participants stories with anyone outside of the group.


General Release of Liability: The undersigned (parent/guardian) agrees to release, waive, discharge, and hold harmless Mindful Moments LLC, its owner, trainers/facilitators, employees, agents, and volunteers from any and all claims, suits, losses, or related causes of action for damages during or arising in any way from participation in Mindful Moments LLC training events.


Fees: Workshop series will run on a 6-week cycle and each session will last for 60 minutes. The fee for the workshop is $270 and payment will be collected prior to first session.  We ask incoming members to make a 6-week commitment when they join a training group. Make up sessions will be at the discretion of the owner of Mindful Moments LLC.

Photograph/Video Waiver: By selecting "Yes" I give permission to Mindful Moments LLC, to use photographs, videotapes, film and audio in which my child appears as a participant for educational and publicity/promotional purposes for or related to Mindful Moments LLC.
Select “I accept” to show that you are signing this Agreement electronically and your electronic signature is the legal equivalent of your manual signature on this Agreement, and agree to abide by the above conditions presented by Mindful Moments LLC.

Thanks for completing our consent form. We look forward to an exciting learning opportunity for your child!

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