Who are the services for? *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent/Guardian *

First Name

Last Name

Phone Number *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Academic Academy *

Check all services that apply.

College and Career Coaching

Educational Consulting

Life Skills Coaching

Mentoring

Parent Advocate

Tutoring

Other

Faith & Fitness *

Check all services that you want information about.

Fitness Coaching

Health and Wellness Workshop

Intensive In-home Counseling

Nutritional Planning

Meal Preparation

Mental Health Skill-Building

Workout Plans

Yoga

Other

Terms and Conditions *

User Agreement: When you request services, you agree that Change Makers United, Inc. and its affiliates will not be liable for any damages or injuries resulting from the use, or inability to use services. By submitting a request for services, you acknowledge and agree to the above stated terms and conditions. If you do not understand the terms and conditions, do not submit a request for services. Do you understand the terms and conditions?

Yes