Teens & Young Adults of Color Online Retreat

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INSTRUCTIONS

This application will take about 30 to 60 minutes.

iBme will keep confidential all information provided in this application except as required for participation in the Retreat or as otherwise required by law, and:

1) If you are under 18 all information will be viewable by your parent / guardian.

2) Your parent / guardian will also need to provide a signature on some pages.

Questions? registrar@ibme.com | (978) 254-7082

ABOUT THE PARTICIPANT

What is your name?



What is your birthday and gender?




What is your contact info?
We require you to provide both teen and parent email addresses (for teens under 18) - we like to be able to communicate directly with parents AND teens.


TEEN ADDRESS & INFORMATION

What is your address?






Please note that by submitting this application you agree to be added to our mailing list. You may unsubscribe from our list at any time.

Ways You Identify
Why do we ask for this information? We are committed to diversity and we want to know more about you and how your lived experiences contribute to your unique identity so we can better support all participants. Sharing the various ways that you identify also helps us to communicate and share with the wider world the diversity of teens that attend our retreats, and that all are welcome. Some of this information will be collected for data (without your names or personal info) to share with donors and other supporters who want to know the broad impact our retreats have.




School

How did you hear about this retreat?











PARENT / GUARDIAN INFORMATION

Parent  / Guardian


We encourage you to provide both teen and parent email address - we like to be able to communicate directly with parents AND teens.









Please note that by submitting this application you agree to be added to our mailing list. You may unsubscribe from our list at any time.

LEARNING ABOUT YOU

These questions MUST be answered by the teen.









Admissions Phone Call
After you submit this application, you will receive an email with instructions on how to schedule your admissions phone call with an iBme staff member. This call is a required part of the admissions process. Please note that your acceptance into the retreat is contingent upon our review of your application and your admissions call.




HEALTH FORM

Special Medical Needs



Mental Health




Substance History


We require that teens in recovery have at least 3 months of sobriety before the start of the retreat in order to attend.


We have a zero tolerance policy
for the use of alcohol, marijuana, and illegal drugs during the retreat.
Confirmation from Teen


LIABILITY WAIVER

Please read this waiver and sign at the bottom.

1. VOLUNTARY APPLICATION, ACCURACY OF INFORMATION
I acknowledge that I have voluntarily applied to participate in the Inward Bound Mindfulness Education, Inc (iBme, Inc) retreat for teenagers and/or young adults entitled Teens of Color East Online Retreat, which will take place virtually. I acknowledge that all information on this application is accurate and complete - including all medical information.

2. RELEASE

As consideration for being permitted by iBme, Inc and the retreat facility to participate in these activities and use their facilities, I hereby agree that I, my parents, my guardians, my assignees, heirs, distributees, and legal representatives will not make a claim against, sue or attach the property of iBme Inc or facility, their affiliates, employees, agents or volunteers or any of their affiliated organizations for injury or damage resulting from acts, howsoever caused, by any employee, agent, or contractor of iBme Inc or facility, or any of their affiliated organizations, as a result of my participation in this event, except when an employee, agent, or contractor of iBme Inc and facility, or any of their affiliated organizations exhibits gross negligence or intentionally acts in a manner likely to lead to my being harmed. I hereby release iBme, Inc, facility and any of their affiliated organizations from all actions, claims or demands that I, my parents, my assigns, heirs, distributees, guardians, and legal representatives now have or may hereafter have for injury or damage resulting from my participation in this event, except when an employee, agent, or contractor of iBme Inc or facility or any of their affiliated organizations exhibits gross negligence or intentionally acts in a manner likely to lead to my being harmed.

3. KNOWING AND VOLUNTARY EXECUTION

I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and a contract among myself, iBme, Inc, facility and/or their affiliated organizations, and sign it of my own free will.

4. VIDEO/AUDIO

I do hereby confirm the consent given you with respect to your photographing or recording me or my child in connection with the iBme, Inc Teen Retreat. I hereby grant to you the right to use all the videos, photographs, and audio recordings which you may make of me or my child, and the right to use my name and/or child’s name or likeness in or in connection with publicly displaying the retreat or any other use of such video, picture, or audio recording.


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PAYMENT

The tuition for this retreat is a sliding scale up to $150

Required Deposit: A deposit of 30% of the total payment is required to hold a retreat space.

Required Application Fee: A minimum payment of $10 is required to process this application.

Discount Code

Please note that all discount codes are applied manually upon application review. If you have a valid discount code the tuition amount listed below will be adjusted accordingly when we review your application.
Tuition Amount (pay what you can up to $150)
Tuition amount: $

Deposit amount: $
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Apply for Scholarship Assistance

iBme is committed to accessibility. We have developed our tuition structure to accommodate a wide range of family income. Scholarship approval is based on available funds and is awarded on a first come, first served basis. We will meet 100% of each family's need until the funding is gone.

The iBme sliding scale guideline is for participants to pay 1% of annual family income.


$
Your Tuition: $


Please pay the deposit amount shown below.

We will review your extenuating circumstances. Please pay the deposit amount below.
Your Deposit: $

Payment Info


Enter amount to pay: $
Current retreat payment: $
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All transactions are securely processed through Authorize.net
Make check payable to iBme, Inc. and send to: iBme, PO Box 516, Concord, MA 01742
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Would you like to include a scholarship gift to iBme with your payment?

Making a gift to iBme helps us maintain our generous scholarship aid: 
we have never turned a teen away for lack of funds.

iBme, Inc. is a tax-exempt 501(c)(3) charitable organization. Your contribution is tax-deductible to the extent allowed by law.




$


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Cancellation Policy:

IIf you cancel up to 7 days before the retreat, you will be refunded in full. If you cancel within 7 days of the retreat start, we will refund you less $50 administrative fee. If you paid less than $50 total for retreat, and cancel within 7 days of retreat, we will keep your full payment. There is no refund if you decide to leave the retreat early. You may also refer to our cancellation policy on the retreat cancellation policy page of our website.


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Instructions for Submitting Your Application

1) Press "SUBMIT" to proceed to the electronic signature page.

2) Review your application to make sure there are no mistakes.

3) Your electronic signature verifies your signature on all forms, and that your application is accurate to the best of your knowledge.

IF YOU ARE UNDER 18, the electronic signature process MUST be completed by your parent / guardian. They will be able to view your entire application.
If you do not receive a confirmation email, please check your spam folder! If you still haven't received anything, please email registrar@ibme.com.
Current Retreat Payment: $
Gift Amount: $
Credit Card Processing Fee: $
Total Current Payment: $

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