FOR GRADES: K-12
    PLACE: A pre-determined place set by the parent and BMYD.
    COST: Affordable cost will vary depending on package - discounts apply. (money order or credit card accepted, no cash)
    REGISTRATION FEE (NON-REFUNDABLE): $25.00 per student.
    PAYMENT SCHEDULE: Session fees are due prior to mentoring services being rendered.
    Program: Support youth with critical thinking, development, peer pressure, positive reinforcement, etc.

    Personal Information: To be completed and electronically signed by the student's parent/guardian. If you don't have a credit or debit card, you can send a money order for the mentor cost and registration fee to the following address: Bright Minds Youth Development • P.O. Box 441963, Jacksonville, FL 32222


    Student Name*: Age*: Date of birth*: 2020-21 Grade level*:

    School*: Graduation Year*:

    Area(s) of concern*:

    Student Name: Age: Date of birth: 2020-21 Grade level:

    School: Graduation Year:

    Area(s) of concern:

    Student Address*:

    City*: State*: Zip*:

    Primary Parent/Guardian Email 1*:

    Secondary Parent/Guardian Email 2:

    Primary Parent/Guardian Name:

    Cell: ()

    Home: ()

    Secondary Parent/Guardian Name:

    Cell: ()

    Home: ()

    I authorize BMYD to contact and coordinate with my child’s teacher?* YesNo

    Best day(s) for mentoring?* MTUWTHURFRISATSUN

    Best time(s) for mentoring?*

    PLEASE NOTE: if you schedule a session and do not cancel within 24 hours of the session, the fee will be NON-REFUNDABLE.

    I have read and I fully accept the terms and conditions concerning Bright Minds Youth Development, Inc. (BMYD) mentoring program. I understand that I am volunteering to enroll my child in BMYD mentoring program and understand that by doing so does not guarantee any positive results in my child’s attitude, grades, development, self- esteem, etc. I understand that this is also a release of Liability, Waiver of all possible claims and assumption of risk, made by me, the undersigned Releaser, on my behalf and on the behalf of my child (if Releaser is under 18 years of age), to BMYD Mentoring and its individuals participating in mentoring sessions offered by this organization. I hereby agree as follows: To waive any and all claims that I have or may, in the future, have against BMYD Mentoring and its volunteers, its directors, officers, mentors and representatives (all of whom are hereinafter collectively referred to as Releasees) To release the Releasees from any and all liability for any loss damage, injury or expense that I or my child may suffer as a result of my participation in this mentoring program, due to any cause whatsoever, including negligence. All decisions made by me are my own, and the Releasees will not be responsible for any consequences arising from these decisions. To hold harmless and indemnify the Releasees from any and all liability for any consequences that may result from my reliance on information given through the mentoring service. This agreement shall be binding upon my heirs, next of kin, executors, administrators, assigns and representatives. This release is intended to cover all matters of injury, damage or loss, (be they tort, contract or otherwise) whether known, unknown, foreseeable, unforeseen, patent, latent, regarding injury abuse or damage to property or person. I freely accept and fully assume all risk, dangers, hazards, and the possibility of personal injury, death, property, damage or loss resulting from my participation in this mentoring program. I agree to abide by the mentoring policies set by BMYD. I understand that program policies are subject to change at BMYD mentoring discretion and understand that if I do not abide by these policies, this may result in the disqualification and removal of my participation in the mentoring program.

    Parent/Legal Guardian Signature*:


    (By entering your name, you agree to accept the terms of the above document with an electronic signature.)

    (Once you have completed the registration form on this site and hit submit, the Mentor Director will reach out to you and discuss the specific needs you have and go over our programs in detail. When mentoring packages are selected and confirmed the office administration will provide you a username and password to review and pay the invoice.)