THE SELF-LOVE SYLLABUS SUMMER INTENSIVE

Permission Slip & Program Agreement
Love Is The Verb, LLC | Karlyn Benn, MS, LPC | Atlanta, GA

Program Description

The Self-Love Syllabus Summer Intensive is a five-day group wellness program for adolescent girls ages 12–15, facilitated by a Licensed Professional Counselor. The program is educational and developmental in nature. It is not therapy, counseling, or psychological treatment. Participation does not establish a clinical relationship between participants and Love Is The Verb, LLC or its staff.

Program Dates & Times

Session 1: July 6–10, 2025 | Session 2: July 13–17, 2025
Monday–Thursday: 9:00am–4:00pm | Friday: 9:00am–1:30pm
Location: Metro Atlanta (specific address shared upon registration)

Parent/Guardian Consent

By signing below, I confirm that:

1. I am the parent or legal guardian of the student named in this registration.
2. I grant permission for my daughter to participate in The Self-Love Syllabus Summer Intensive.
3. I understand this program is educational and wellness-focused, not clinical therapy or counseling.
4. I understand that group discussions may include topics related to emotions, identity, relationships, self-image, peer dynamics, and age-appropriate, professionally guided conversations around sexuality and sexual health, and I consent to my daughter's participation in these discussions.
5. I agree to ensure my daughter's timely arrival and prompt pickup at the end of each session. We know life gets full, and we appreciate your care in honoring the schedule.
6. I understand I will be contacted immediately in any situation requiring a parent/guardian response.

Authorized Pickup

For the safety of every participant, your daughter will only be released to the parent or guardian listed in this registration, or to an individual you have specifically authorized in writing. If someone other than the registering parent or guardian will be picking her up on any day, please notify us in advance by email at Karlyn@LoveIsTheVerb.com. At pickup, please text the word here from the phone number used during registration to 404.809.6801 so we can release her promptly. We know this may feel like a lot, and it is simply our way of making sure every girl leaves with exactly who she is supposed to leave with.

Health & Safety

1. I have disclosed all relevant medical conditions, allergies, and accommodation needs in the registration form.
2. I authorize Love Is The Verb, LLC staff to seek emergency medical care for my daughter if I cannot be reached and her condition requires immediate attention.

Medications

If your daughter takes medication during the day, she is welcome to bring it with her. Participants are responsible for self-administering their own medication. Love Is The Verb, LLC staff will not administer medication of any kind. Please ensure your daughter knows her dosage and timing, and notify us of any medications she carries so we are aware in the event of an emergency.

Cell Phones & Technology

Cell phones are welcome. We simply ask that they be put away during our sessions so that every girl can be fully present with herself and with the group. Phones may be used freely during lunch and any scheduled breaks.

Lunch & Food

Participants are responsible for bringing their own lunch each day. On the final day of the session, we will celebrate together with a showcase, and pizza is on us. If your daughter has any food allergies or dietary restrictions, please make sure they are noted in the registration form so we can plan accordingly.

Photo & Media Release

I grant Love Is The Verb, LLC permission to photograph and/or record my daughter during the program for use in promotional and educational materials, including social media and the program website. If you do NOT consent, indicate below using the checkbox beneath this agreement.

Confidentiality & What Gets Shared

What is shared inside the room stays inside the room. Participants are asked to honor the privacy of every girl in the group, and that standard is held by the facilitator as well. Karlyn will not share the specific content of your daughter's disclosures with you without her knowledge, unless safety requires it.

There are, however, limits to confidentiality that we want you to know about in advance.

Mandated Reporting

Karlyn Benn is a Licensed Professional Counselor and a mandated reporter under Georgia law. This means that if your daughter discloses information that suggests she or another person may be in danger, including abuse, neglect, or risk of harm to self or others, Karlyn is legally required to report that information to the appropriate authorities. In the event a report is made, Karlyn will communicate with you as fully and transparently as the situation allows.

Behavioral Agreement

I understand that respectful participation is required. Love Is The Verb, LLC reserves the right to remove a participant from the program without refund if behavior is disruptive, harmful, or inconsistent with the program's values of safety and mutual respect.

Cancellation & Refund Policy

Cancellations made at least two weeks before the session start date: 50% refund.
Cancellations made less than two weeks before the session start date: No refund.
If Love Is The Verb, LLC cancels the program: Full refund issued.

Release of Liability

To the extent permitted by law, I release Love Is The Verb, LLC, its officers, employees, and contractors from liability for any injury, loss, or damage arising from my daughter's participation, except in cases of gross negligence or willful misconduct.

By typing my name and submitting this form, I acknowledge that I have read and agree to all terms above, and I understand that my typed name constitutes a legally binding electronic signature under the Electronic Signatures in Global and National Commerce Act (ESIGN, 15 U.S.C. § 7001 et seq.).