Registration09/26/2026 | MAB Wellness Outreach

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1. First name (Parent/Guardian)*

Last name*

2. Email*

3. Phone*

4. City*

5. Zip Code*

6. Children Attending: How many children will attend? For each child please provide: Name and Age:*

7. Attendance*

Parent/Guardian Only

Parent/Guardian with child(ren)

8. Emergency Contact ( Name and Phone):*

9. Dietary Needs- Does anyone have food allergies or dietary restrictions?*

10. Is this your first MAB Wellness Outreach Youth Mental Wellness event?*

Yes

No

11. Donation Registration Fee (Tax-Deductible)- Please select your registration option.

Family Registration- $20

Individual Parent/Guardian Registration- $10

Scholarship Registration (Community Partner Referral)

Your donation helps MAB Wellness Outreach provide mental wellness education, healthy lifestyle programming, meals, materials, and scholarship opportunities for individuals and families with limited resources.

12. How will you pay your donation registration fee?

PayPal- (See 13.)

CashApp- $MikeChellEvents1

Zelle- seeb211@yahoo.com or 757-770-2971

Check- ( Make out to: MAB Wellness Outreach

13. If you selected PayPal above, please click the appropriate registration link below to complete your payment.

PayPal – Youth Mental Wellness Family Registration ($20)

→ Link: https://www.paypal.com/ncp/payment/JF2UT54TT2HRW
PayPal – Youth Mental Wellness Individual Registration ($10)

→ Link: https://www.paypal.com/ncp/payment/DNP4FBM3KNTXE

14. Scholarship registration- Please provide the community partner or referring staff if known.

15. Photo & Video Permission*

YES – I give permission for myself and any child(ren) I register to appear in photographs and/or video recordings.

○ NO – I do not give permission for myself and/or my child(ren) to appear in photographs and/or video recordings.

Liability & Participation Acknowledgement -
I voluntarily participate and authorize any child(ren) I register to participate. I understand participation is at our own risk. MAB Wellness Outreach provides education, not medical or mental health treatment, and I release MAB Wellness Outreach, its staff, volunteers, instructors, sponsors, and partners from liability, except where prohibited by law.
I have read and agree. ( Please check on the left.)

*

STAY CONNECTED

Mailing Address:

P.O. Box 6023

Portsmouth, Virginia 23703

Email: info@mabwellnessoutreach.org

Phone: 757-533-2677

MAB Wellness Outreach

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