BlessedGirl Mentee Application

Member Information
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number *

Area Code Phone Number
Email Address:
example@example.com
Gender *

Male Female N/A
Date of Birth: *

Month Day Year
Date
Age *
School Name:
Town/City of School:
Grade (As of September)
Parent/Guardian Contact Information
Parent/Guardian #1
Name *

First Name Last Name
Relationship to Member: *
Employer:
Occupation:
Phone Number 1: *

Area Code Phone Number
Phone Number 2:

Area Code Phone Number
Parent/Guardian #2
Name

First Name Last Name
Relationship to Member:
Employer:
Occupation:
Phone Number 1:

Area Code Phone Number
Phone Number 2:

Area Code Phone Number
Emergency Contact Information
Name

First Name Last Name
Relationship to Member:
Contact Number:

Area Code Phone Number
Name

First Name Last Name
Relationship to Member:
Contact Number:

Area Code Phone Number
Member Medical Information:
Does your child have any chronic or acute illnesses?

Yes No
If yes, please explain:
Does your child have any learning disabilities?

Yes No
Any prescribed medications?

Yes No
IN CASE OF EMERGENCY, I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO CONTACT ME. IN THE EVENT THAT I CANNOT BE REACHED, I HEREBY GIVE PERMISSION TO THE HOSPITAL AND ATTENDING PHYSICIAN SELECTED BY BLESSEDGIRL. TO TAKE ANY NECESSARY ACTION, INCLUDING SURGERY, ANESTHESIA, OR INJECTIONS, THAT IS IN THE BEST INTEREST OF MY CHILD.
MEDICAL DECLARATION STATEMENT FOR SCHOOL-AGE CHILD CARE
Child's Name:
Date of Birth:

Month Day Year
Date
Grade:
School:
Is your child under any medical/physical restrictions?

Yes No
If yes, check all that apply:

Asthma Diabetes Seizures Hearing Loss
Is your child taking any medications?

Yes No
If Yes, please list:
Has your child been under a doctor's care or hospitalized within the last 3 years?

Yes No
If yes, please explain:
Is your child allergic to any medications, foods or insect stings?

Yes No
If yes, please explain:
Physician's Name:
Address:
City:
State:
Zip:
As a parent/guardian of the above participating child, I certify that he/she is in good physical health, has no special needs, and may participating in all of the activities of the BLESSEDGIRL program, except as noted above.
Parent/Guardian Signature: *

Clear
Date:

Month Day Year
Date
Should be Empty:

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Member Information

Parent/Guardian Contact Information

Parent/Guardian #1

Parent/Guardian #2

Emergency Contact Information

Member Medical Information:

MEDICAL DECLARATION STATEMENT FOR SCHOOL-AGE CHILD CARE