If parents share custody of the minor/s, both parents must consent for the participation of the child.

Parents will only submit this registration form one time.
Do you provide consent to text? *
Do you provide consent to text? *
Do you share custody? *
Do both parents consent for services? If so sign below. Please know both parents will be contacted. *

Please provide the address where the child/teen will be during classes.

The child lives with: *

Child information

Does your child have medical issues? *
Does your child require special needs accommodations? *
Does your child have medical issues?
Does your child require special needs accommodations?
Does your child have medical issues?
Does your child require special needs accommodations?

Behavior & Participation Policy

I agree and understand that Young Minds Services strives to create a safe, positive experience for all the children. If my child becomes disruptive, disrespectful, or a danger to himself or others, I understand that I will be called to remove my child from the workshops (when in person). If a minor is disrespectful, not involved in the class and/or disruptive via Zoom the parent will be informed of the possible removal (only one warning is given). If the child continues to disrespectful after the 1st warning, the child will be automatically removed from the Zoom class.
We understand that children learn differently and may require time to learn, a plan will be deveolped with parents to help the child succeed. If the 1st plan does not work a second plan will be developed only if parents demosntrate cooperation to solve the issue, the child is willing to attend the classes, and if the facilitator agrees that continuing to develop a plan is beneficial. All of these three must be checked off as yes to develop a second plan. Each situation is different and please know we will do our best to find a solution. If all three are not checked means that the child may benefit from in person activities/services. Three resource list will be provided for parents to consider. 
 Please know virtual classes may not be a good fit for some children and would benefit from in person classes. Parents are encouraged to have their child try one class at a time to confirm if the Young Minds Services classes. 
Once the child attends a workshop, leaves early no matter what reasons, or is removed due to misbehavior there is NO Reimbursement. 
The child will only be removed from the program if,
The child is being disrespectful and/or disruptive after notifying the parent 2 times even after a plan has been made.
The child shares he/she does not want to be part of the class (no child can be forced to attend the classes)
The child makes threats of any kind towards staff and group members. ex: talks back, curses, uses inapropirate, sexual gestures/noices, or any other behavior that is or appears disrespectful towards staff or group members.
The parent/s become disrespectful towards staff.
The child and parent do not demonstrate efforts to improve the behavioral issues.
PARTICIPATION: A child must try their best to participate in classes. We understand that a child may be shy the first class upto the 4 class. Chidlren are encouraged to participate by:
Asking questions 
Sharing their input on the questions asked
Not laying down while on Zoom
Sitting in a non distracting room area
No eating to avoid distrations
No walking 
No multitasking
New rules to the behavioral and participation policy may be added without notice to assure the safety of the minors. 
Children have many strengths and will be acknowledged at the end of each class. Each child will receive an email certificate acknowleding their strength.
Minor must have a working electronic and Wifi to assure he/she is able to listen and participate in the class. Preferrably a laptop or Ipad if possible. 
Note: Please have your cell phone turned on while children are participating in the workshops.
I have read the entire behavioral and participation policy. I understand and agree on the agencies policy. I am aware that my involvement is very important for my child to take as much as possible from the classes. *

Emergency contacts

Relationship to child *
Relationship to child *

Tardiness & Photograph Policy

Tardiness & No Show:

Children are only allowed to be late 5 min. If a child is late they will be credited for the next class and not admited to the class. If there is a pattern of being late 2 or more times, there will not be any credits for payments. If a child shows up late they will not take the full advantage of the class topic. If the child does not show and the parent did not notify the agency we do not give credit or rehimburse for the missed class. Parents are encouraged to contacted within 24 hours that the child will not be attend to be able to get credited for the next class.

I the parent agree that I am responsible to make sure my child is ready 3 min before class starts and to attend the classes as best of my ability. *
I understand that Young Minds Services activities may be photographed or videotaped for promotional purposes. I authorize Young Minds Services to use those photos, videos, or other digital reproductions of my child for publication purposes, including online advertising.(if you decline please list below) *

Consent For Services

I, the undersigned parent(s) or guardian(s), hereby give permission for my child, to participate in the activities connected with the

Young Minds Services (the “activities”). I understand that the activities will include the following: virtual activities, crafts, lectures, and educational videos.

I certify that my child is able to participate in any and all of these activities. In the event that an emergency occurs, I may be reached at my alternative number if my child is using a parent's cellphone. I agree that I or another adult family member will remain available if needed. If there are any activities in which I do not want my child involved, I will email the instructor.

In the event that my child becomes ill during any game or activity, I hereby authorize Young Minds Services or its representative to seek medical treatment (Young mind Services is not responsible for any medical fees such as ambulance cost), including but not limited to securing the services of a physician or hospital. I will assume responsibility for all medical expenses incurred.


I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS THAT MAY BE ENCOUNTERED ON SAID ACTIVITIES, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do, for myself and for my child, heirs, and assigns, to the fullest extent permitted by law, hereby irrevocably and unconditionally release, acquit, and forever discharge Young Minds Services, and their agents, employees, and volunteers from any and all liability, actions, causes of actions, claims, expenses, obligations, and damages of any nature whatsoever, which I now have or which may arise in the future, in connection with my child's participation in the described activities or in any other associated activities including, but not limited to, any injury to my child or property, even injury resulting in death.

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the laws of California and that if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto.




1st step

Each class is 4 weeks attending 1x wk for 30min. Parents can make the payment per week (payment must always be made the day before) OR pay 4 weeks in advance. A one time registration fee is made for each child NO REHIMBURSMENT.
Each class is the same fee unless there are additional activities being provided which will be an additional cost and parents will be informed in advance if they decide to have their child participate.
Opened for Enrollment. Please choose your option: Classes begin June 2, 2022 until June 23, 2022 Every Thursday for 4 weeks *

2nd step

Please make sure to check off BOTH registration and class fee 
Registration. One time fee *
Class Payment Options: *

3rd step

What other classes would you be interested in?


Payments for the next upcoming classes will be paid via Zelle, Venmo, or Paypal. Parents will be provided with the links via email. 
Current Total:
Please make sure to successfully complete payment through PayPal as a guest if you do not have an account.
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