Coaching Enrollment Request

Coaching Enrollment Request

Student Information

Student Name:

Date of Birth: Student ID:

Parent / Guardian (if applicable)

Relationship: Phone:

Coaching Program Details

Coach Preference: Proposed Start Date:

Weekly Biweekly Monthly One-time

In-person Remote / Online Hybrid

Fees & Payment

Tuition / Fee Amount: Billing Contact Name:

Full payment Installments

I authorize the program to process payments in accordance with the selected plan and to charge the payment method provided for agreed fees and applicable late fees.

Health & Emergency Information

Relationship: Phone:

Physician / Clinic: Phone:

In the event of an emergency, I authorize program staff or the coach to obtain medical care for the student when I cannot be reached, and I agree to be financially responsible for such care.

Policies, Acknowledgments & Release

Enrollment is subject to program availability and acceptance by the coaching provider. All fees are due according to the selected payment plan. Late payments not resolved within 14 days may result in suspension of services until the account is current. Late payments incur interest at a rate of 1.5% per month on unpaid balances and any collection costs.

Cancellation and Rescheduling: Client must provide at least 72 hours' notice to cancel or reschedule a scheduled session to avoid being charged for the session. Cancellations within 72 hours or no-shows are subject to full session charge unless otherwise agreed in writing.

Conduct and Safety: The student agrees to follow reasonable conduct and safety directions provided by the coach or program staff. The program reserves the right to discontinue services for behavior that threatens safety or undermines program objectives; no refund will be provided for services terminated for cause.

Confidentiality & Recording: Coaches will maintain confidentiality of personal information to the extent practicable; however, coaches may disclose information when required by law or to protect safety. Recording or rebroadcasting sessions is prohibited without prior written consent from the coach and program.

Liability Release: By signing below, the undersigned releases, holds harmless, and indemnifies the coaching provider, its coaches, employees, and agents from any and all claims, liabilities, damages, or expenses arising out of participation in coaching services, except claims resulting from willful misconduct or gross negligence by the provider.

Data and Communications: I consent to receive communications related to scheduling, billing, and program updates by phone, text, or email at the contact information provided. I confirm that information provided on this form is accurate to the best of my knowledge.

I acknowledge that I have read, understand, and agree to the policies and terms set forth above and authorize enrollment of the student in the requested coaching services.

I consent to the limited use of photographs or video of the student for program promotional or training materials, provided no personally identifying information is published without additional consent.

Certification

Certification: I certify that the information provided on this Coaching Enrollment Request is true and complete. I understand that submission of this form constitutes a request for enrollment and that services will commence upon written confirmation of acceptance and receipt of agreed payment.

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