Registration Form - Minor - IGNITE Peak Performance

Peak Performance Coach

Client First Name:*

Client Last Name:*

DOB:*

Date:*

Client Information

Name:*		Date of Birth* MM slash DD slash YYYY	Ethnicity/Race*
Street Address:*	City*	State:*	Zip:*
Home Phone:*	Cell:	Gender:* Male Female	Preferred Pronouns:*
School:*		Grade:*

Parent/Custody Information

Emergency Notification (Must be a local person.)

Telephone and Written Communication

Dr. Stephen may leave telephone messages for me with her name, telephone number, and information related to appointment dates, times, and changes at the following telephone number(s):
Number(s)*
Dr. Stephen may send written correspondence to me at the following address:
Street:*	City:*	State:*	Zip:*

My signature below indicates that the information cited above is true, accurate, and current.

Client Signature*	Client Name*	Date* MM slash DD slash YYYY
My signature below indicates the information cited above is true, accurate, and current; I am legally allowed to obtain coaching services for:
Name of Client:*
That if I am required to inform any other party of the client’s participation in coaching services I have done so.
Parent/Guardian Signature*	Parent/Guardian Name*	Date* MM slash DD slash YYYY
Parent/Guardian Signature	Parent/Guardian Name	Date MM slash DD slash YYYY

PO Box 1034, Jericho, VT 05465 • drstephen@ignitepeakperformance.com • 802-355-9299 • ignitepeakperformance.com

BUILDING THE MINDS OF CHAMPIONS