Mindful Self-Compassion for Teens After School Program Registration Form
Hello! We are excited to have you join our eight-week series in Mindful Self-Compassion for Teens. This program will help teens gain skills and practices to weather the ups and downs of life with greater resiliency. 

Our program begins Wednesday, February 8th and runs for eight weeks through Wednesday, March 29th. The series will be held at The Nest, a new coffee shop focused on youth in Uptown Port Townsend. The Nest is located at 1119 Lawrence Street. Classes will be held on Wednesdays, 4:15-6:00 pm, with a 15 minute break in the middle of each session. Classes will include art, journaling, light movement, and some meditation practices, as well as discussions of topics related to Mindful Self-Compassion. Snacks will be provided.

This series costs $250 for the full tuition, but we have generous scholarships available. To receive a scholarship all you have to do is select the prorated amount that matches your ability to pay in the form below.  This work is important to us, and we are grateful for everyone who participates in our programs regardless of your ability to pay. 

Please complete and submit this registration form to reserve your teen's place in the program. Once we receive your completed registration we will reach out to finalize payment arrangements based on the options you select below.

We look forward to beginning this journey of self discovery with you.

Sincerely,
Teresa Shiraishi, Lead Instructor and Aleah Lawrence-Pine, Teaching Assistant
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Participant Information
Participant's Name (First and Last Name) *
Name Participant Prefers to Go By (if different from legal name)
Participants Age on February 8, 2023 *
Participant's Pronoun
Participant's Email Address
Participant's Phone Number
Does the participant have any food allergies?
Does the participant have any previous experience with mindfulness, meditation, or self-compassion curriculum?
Is the participant currently under the care of a therapist or psychiatrist? Please share with us any details or circumstances that may affect your child’s ability to participate fully in the program including behavioral, psychological, medical, or physical conditions.
What do you hope the participant will get out of this experience?
Is there anything else you would like to tell us about the participant, including special accommodations that might be needed?
Parent/Guardian Information
Parent/Guardian Name *
Parent/Guardian Email Address *
Parent/Guardian Phone Number
Mailing Address (Street)
Mailing Address (City)
Mailing Address (Zip)
Emergency Contact Name *
Emergency Contact Phone Number *
Liability Waiver and Photo Release Forms
Liability Waiver:
I, as parent/guardian of the participant named above (Child), hereby assume all risks and hazards incidental to the conduct of the activities at The Benji Project program. I acknowledge that, by agreeing to this document, I am releasing The Benji Project, their representatives, agents, employees, volunteers, members, sponsors, promoters, and affiliates (collectively Releasees) from liability. I hereby release and shall defend, indemnify, and hold harmless Releasees from every claim and any liability that I or my child may allege against Releasees (including reasonable legal fees and costs) as a direct or indirect result of injury or death to my child because of my child's participation in The Benji Project program, whether caused by the negligence of releasees or others to the maximum extent permitted by law. I promise not to sue Releasees on my child's behalf regarding any claim arising from or related to my child's participation in The Benji Project program. This form is a contract with legal and binding consequences, and it applies to all activities in which my child engages during the program, regardless of whether such activity is a part of a formal program. I understand that no insurance coverage for participants in these activities is provided by The Benji Project. I have read this release carefully, and I understand what this release means and what I am agreeing by typing my name and clicking the "I agree" box below.
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Name of person agreeing to the Liability Waiver above.
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Photograph & Video Release Form:
I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape, for the purposes of use by The Benji Project, without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed online, and I waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I understand that this material is intended for the purpose of promoting The Benji Project, a nonprofit organization. I authorize The Benji Project to make use of my appearance for this purpose. By signing this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in a public educational setting. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. By clicking the "I agree" button below and tying my name, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.
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Name of the person agreeing to the Photography & Video Release Form above. *
Payment Information
Tuition Levels: 
Please choose the tuition level that matches your able to pay. We offer this course at subsidized rates to make it accessible to our community. Please choose the full tuition option if you are able to help us keep our programs funded. If you are able to contribute additional funds above full tuition, this helps us offset scholarships we offer to other students.
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Payment Method:
Please choose the payment method that is most convenient for you. We will reach out once we receive your completed registration form to finalize payment arrangements with you.
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A copy of your responses will be emailed to the address you provided.
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