Youth Development Coaching for the Blind Enrollment Form

Please fill out and submit the form below to enroll in our coaching services, then submit your payment by clicking here

Parent’s Full Name

Child's Full Name

Contact Email

Contact Phone

City

State

Child’s Age

Child’s Sight Status (check one) Child’s Sight Status (check one) Totally blind Very low vision Legally blind

Site Status for How Long

Child Primarily Reads (check one) Child Primarily Reads (check one) Braille Print Large print Audio Computer format

Child’s grade level

Child’s Current GPA

Child’s Overall GPA

Child’s extracurricular activities (if any).

List two areas mentioned in the service overview video that you would like to address during this coaching session(s):

Type a brief description of your concerns for your child in these two areas:

9 + 10 =

Disclaimer: I have read and accept the legal disclaimer for this service (check box to check with this disclaimer displayed below, or a button to click to read it). Legal Disclaimer Notice All information shown on this website or expressed during coaching sessions is intended to be general information with respect to common Life issues. Information is offered in good faith – you do not have to use this information.

The information contained within Blackboysincrisis web site is not a substitute for professional advice such as a Medical Doctor, Psychiatrist, or counselor. The information provided by CBM Consulting And Coaching via Blackboysincrisis does not constitute legal or professional advice neither is it intended to be.

Any decisions you make, and the consequences thereof are your own. Under no circumstances can you hold CBM Consulting And Coaching or Blackboysincrisis liable for any actions that you take. You agree not to hold CBM Consulting And Coaching, Richard Clay, or any employees or subsidiaries of CBM Consulting And Coaching, liable for any loss or cost incurred by you, or any person related or associated with you, as a result of materials or techniques, or coaching, offered by CBM Consulting And Coaching.

Nothing in the content materials of these coaching sessions shall be considered legal, financial, or actuarial advice.

Blackboysincrisis.com reserves the right to refuse service for any reason. Results are not guaranteed. Blackboysincrisis.com holds no responsibility for the actions, choices, or decisions taken or made by the client.

Diagnosing psychological or medical conditions is for trained medical professionals (Physicians and Therapists), not for a Life Coach.

All information shared for billing or for sessions is held strictly confidential. Your personally identifiable information is never sold, traded, or given away.