Family Application, Agape Mindfulness Program

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Please complete this application for EACH child in your family who you would like to enroll in our summer mindfulness program for children! (That will mean, if you have more than one child you wish to enroll, that you fill out the form more than one time). Our mindfulness program will be two weeks, the week of July 11th, and the week of July 18th, 2022. Our hours are from 9am-2pm. Children bring their own lunch, and are provided a healthy snack. Children ages 6-11 are welcome to enroll. We have full and partial scholarships for families that have financial need. Reach out to Rachel (rachel@agapewaltham.org) or Tara (tara@agapewaltham.org) with any questions or concerns!

Email *

Your Full Name *

Home phone number: *

What is the full name of your child? *

How old will your child be in July 2022? *

Would you prefer to enroll for just the first week, just the second week, or both weeks of the program? *

Week of July 11th only

Week of July 18th only

Both weeks: Week of July 11th AND Week of July 18th

Which school does your child attend during the school year? *

In which city/town does your family live? *

Which language(s) are spoken at home? *

Does your child have allergies? If so, please describe. *

What are some of your child's interests and strengths? *

Does your child have any special physical or health needs that we should be aware of? If so, please describe. *

Does your child have specific learning and/or behavior needs? If so, please describe. *

How do your family and your child identify racially, ethnically, and culturally? *

How does your child identify in terms of gender? *

Female

Male

Non-binary

Trans

Other:

Required

Program tuition is $150 per week, per child. We have full and partial scholarships available. Please honestly indicate your family's level of need. (If you are enrolling more than one child and paying full tuition for each child would be a financial burden, consider requesting a partial or full scholarship). *

I can pay the full camp tuition ($150 per week).

I would like to request a partial scholarship.

I would like to request a full scholarship for my child.

Send me a copy of my responses.

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