BecomingHER Mentorship - Intake Form | Legacy Lab Academy, Inc.

Contact

Parent / guardian name *

Email *

Cell phone *

Participant

Teen's first name *

Age *

Emergency contact (name and number, if different from you)

Health basics

These help Coach J keep her safe. Answer what you can; skip anything you would rather discuss in person.

Medical conditions or diagnoses I should know about (optional)

Activity restrictions from her doctor (optional)

Has her doctor cleared light physical activity (walking, stretching, mobility work, light weights or medicine balls)?

Yes No Not sure

Allergies (optional)

Current medications (optional)

Support and goals

Who is already in her corner? (optional, e.g. therapist, counselor, tutor, coach)

If we work together for four weeks, what would a win look like for her? (optional)

Anything else I should know before session one? (optional)

Preferred weekly day and time

Agreement

I have read the BecomingHER mentorship participation waiver. I understand this is a confidence and mindset mentorship, not medical care or therapy, that movement stays within whatever her doctor clears, and that no nutrition or eating guidance is provided. I agree to the waiver terms. *

One more step after this: submitting takes you straight to the waiver form to fill out and sign. Both forms are needed before session one.

BecomingHER Intake

Contact

Participant

Health basics

Support and goals

Agreement