Youth Success Dynamics Academy Intake Forms
THIS IS A PREVIEW OF THE SDA INTAKE FORM DOCUMENT
You will receive a link to this form to complete immediately after purchase.
You must submit Forms immediately upon purchase to complete enrollment and registration.
PLEASE READ AND MAKE SURE YOU AGREE BEFORE PURCHASING SUCCESS DYNAMICS ACADEMY.
Failure to submit Forms will result in losing access to the membership portal.
FORM SUBMISSION GUIDELINES FOR RELEASE FORM AND HOLD HARMLESS FORM
Please make sure all involved parties submit this Form. It is part of registering for Success Dynamics Academy. Failure to complete promptly will result in denied access.
These documents must be submitted each year by the following:
- A Parent/Guardian of a Minor-aged Student
- The Party Responsible for Payment
A Parent/Guardian submits the Form for a Minor-Aged SDA Student. However, if the Parent/Guardian is NOT the Party Responsible for Payment, then a separate Form must be submitted by both parties.
Parents/Guardians submit only one Form for a Minor-aged child/children if they are also the Party Responsible for Payment.
PERSONAL INFORMATION
Your Information is never shared or sold!
Correct contact information is vital. It is used here primarily for communicating about Success Dynamics Academy: questions, curriculum, coaching announcements, and reminders. Please include the client's contact information - 14 years old and older - to help make sure communication is open, up to date, and helping everyone arrive at coaching calls and sessions on time.
STEPS TO COMPLETE THIS FORM
The intake system has some limitations, and therefore, you will see fields that need a duplicate answer. In these cases, please write out the correct answer again, instead of "same as above" type answers.
Some fields may not apply to you, but you will need to read and answer those, too (write N/A in those.)
Please fill out all fields correctly to complete the Form.
The SDA Intake Forms are not complete unless you check all the boxes, including both the boxes under each Form, signifying you have read and agree to both the Release & Hold Harmless Forms.
I appreciate your patience!
(FILL-IN-THE-BLANK PERSONAL INFORMATION QUESTION FIELDS ARE HERE.)
SUCCESS DYNAMICS ACADEMY TERMS AGREEMENT
FOR SDA YOUTH MEMBERSHIPS AGES 8-17
SDA-Youth Online Training Procedure:
Success Dynamics Academy (SDA) curriculum has many training sessions. The new curriculum is delivered over time (every 4-8 weeks) into an online portal and is available on specific days and times.
Success Dynamics Academy -YOUTH membership is for children (siblings) aged 8-17. Therefore, each individual family listening to SDA should have purchased it and submitted the proper forms.
Clients have access to SDA until they cancel their subscription; however, once a child turns 18, they should move into the SDA-Young Adult membership.
Contact Peggy to switch to or add the SDA-Young Adult by emailing to:
Clients may listen and review the curriculum through the online portal anytime.
Recording or downloading any of the SDA recordings is not permitted.
Copying, sharing, or otherwise distributing the SDA curriculum or any of its content is not permitted.
RELEASE FORM
For Success Dynamics Academy - Youth (8-17)
I, _________, understand that nothing said, done, performed, typed, printed, or produced by Peggy Nazer is intended or meant to diagnose, prescribe, treat a disease or take the place of diagnoses by a licensed physician, psychologist, or psychiatrist.
Consultations by phone or email, training, coursework, coaching sessions, energy psychology work sessions, Integrative Processing Technique (IPT) sessions, integration sessions, classes, or techniques are to promote healthy lifestyles and cultivate the mind/body connection.
A variety of non-invasive methods, modalities, and programs, commonly referred to as Energy Psychology, may be used, which include but are not limited to, bio-kinesiology (muscle response testing-MRT). MRT is used to determine past events and identify negative emotions stored in certain chakras or energy centers of the body. Guided imagery, NLP, speaking out feelings, role-playing, inner child work, chakra work, visualization, and various Energy Psychology techniques are used. The purpose of using these techniques is to bring the client to a place of inner healing/reconciling and a strong sense of well-being and closure with the issues being addressed.
This form is a release form granting Peggy Nazer permission to release and clear negative energy and process my family member or me through experiences using both conscious awareness and energy release techniques. This authorization is valid for any and all private and group sessions as well as any coursework involving Peggy Nazer.
HOLD HARMLESS FORM
For Success Dynamics Academy - Youth (8-17)
In consideration of receiving life coaching & energy psychology work from Peggy Nazer (DBA Peggy Nazer Coaching), I hereby release, waive and discharge all rights to legal action against and covenant not to sue, and agree to forever hold harmless for any and all purposes, Peggy Nazer Coaching from any and all liabilities, claims and/or demands that may result from coaching and/or energy psychology work, provided by Peggy Nazer Coaching.
My election to receive coaching & energy psychology work or any other services provided by Peggy Nazer Coaching is completely voluntary and at my own discretion. I also hereby acknowledge that Peggy Nazer Coaching does not make any promises or guarantees that her methods will help or cure me of any type of condition or health problem. I voluntarily assume full responsibility for any risks or outcomes that may result from receiving coaching or energy psychology work, whether caused by commission or omission on the part of Peggy Nazer Coaching.
It is my expressed intent that this Covenant Not To Sue and Hold Harmless Agreement shall bind the members of my family, spouse, heirs, and their families and personal representatives. I acknowledge and represent that I have read the foregoing Covenant and Agreement, understand it, and voluntarily agree to it, and its terms in full as my own free act and deed; no oral representations, statements, or inducements apart from the foregoing agreement that has been reduced to writing have been made. I execute this document as full, adequate, and complete, fully intending to be bound by the same, now and in the future.
ALL FORMS MUST BE SUBMITTED BY ALL INVOLVED PARTIES
Completed Intake Forms are required from the SDA student's parent/guardian AND the Party Responsible for Payment of Services. Submit separate forms if these parties are not the same person.
