Date *

MM

DD

YYYY

Who is completing this acknowledgment form? *

Parent/Legal Guardian of minor (Under 18 years old)

Mentee (18 years of age or older)

Name *

First Name

Last Name

If on behalf of a minor (*Under 18 years old), minors name:

First Name

Last Name

I have read, fully understand, and agree with the terms set forth in We R Listening's Confidentiality Policy? *

Yes

No

I have read, fully understand, and agree with the terms set forth in We R Listening's Liability & User Policy? *

Yes

No

I have read, fully understand, and agree with the terms set forth in We R Listening's Testimonial Release? *

Yes

No

I have read, fully understand, and agree with the terms set forth in We R Listening's Photo & Video Release? *

Yes

No