For Parents & Guardians

Parent Waiver & Intake Form

Please complete this form before your teen's first session. It covers emergency contacts, permissions, and our program expectations.

18 or older and enrolling on your own? Use the adult intake & waiver instead.

Parent / Guardian Information

Your full name *Email *Phone *

Teen Information

Teen's full name *Age *

Emergency Contacts

Someone we can reach if a parent/guardian is unavailable.

Contact 1 name *Phone *Relationship *Contact 2 namePhoneRelationship

Allergies & Medical Notes

Allergies (food, environmental, medication)Write 'none' if not applicable.Other medical notes we should knowAnything that may affect participation (optional).

Photo & Media Permission

From time to time we take photos during sessions and circles for use on our website and social media. Faces are only used with consent.

I give permission for photos including my teen to be used in This Little Light Collective marketing and social media. (Optional — leave unchecked to opt out.)

Pickup & Release

Adults authorized to pick up your teen *List full names and relationship (e.g., 'Jane Doe — aunt').My teen has permission to leave the session location on their own.

Acknowledgements

Participation acknowledgement. I understand that participation in This Little Light Collective programs is voluntary, and I release the Collective, its facilitators, and host venues from liability for any incidental injury or loss that may occur during normal participation.This is mentorship & workshop-based, not therapy. I understand This Little Light Collective offers coaching, mentorship, and group workshops focused on resilience and confidence. It is not mental-health therapy, counseling, or medical care, and is not a substitute for treatment by a licensed professional. If my teen needs clinical support, I am responsible for arranging it.Behavior expectations. I have reviewed the group agreements with my teen: kindness and respect toward every participant, confidentiality of what is shared, presence (phones away during sessions), and good-faith participation. I understand that behavior that harms the group may result in being asked to step away from the program.

Stay Connected

Yes, please add me to the email list for updates, resources, and notes from Allison. (Optional — unsubscribe anytime.)

Signature

Type your full name as your signature *Signed today, 7/22/2026