Mindful Monday Registration Form

We are so glad you are deciding to join us! We understand that participating in something new can be challenging, so if you have any questions or concerns, contact our amazingly friendly Program Director, Jodi Beland: jodi@ckgfoundation.org

Student's Name *
Student's Name
Parent/Guardian's Name *
Parent/Guardian's Name
Grade Level *
Media Consent Form *
Media Consent Form
I hereby consent to allow The Cameron K. Gallagher Foundation, and all of its affiliated business/charitable entities, including but not limited to SpeakUp5k, along with their officers, directors, agents, and employees, to use my image, performance, voice, and all other media forms, in their media outreach (including internet, television, radio and print media).
Dates you wish to attend *