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 12–14, 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, and peer dynamics, and I consent to my daughter's participation in these discussions.
5. I agree to ensure my daughter's timely arrival and departure each day.
6. I understand I will be contacted immediately in any situation requiring a parent/guardian.

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 she cannot be reached and her condition requires immediate attention.
3. I understand that Love Is The Verb, LLC is not responsible for pre-existing medical conditions.

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.

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.).