BlessedGirl Mentee Application

Member Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Email Address:
example@example.com
Gender*

MaleFemaleN/A
Date of Birth:*

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

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

Area CodePhone Number
Phone Number 2:

Area CodePhone Number
Parent/Guardian #2
Name

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

Area CodePhone Number
Phone Number 2:

Area CodePhone Number
Emergency Contact Information
Name

First NameLast Name
Relationship to Member:
Contact Number:

Area CodePhone Number
Name

First NameLast Name
Relationship to Member:
Contact Number:

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

YesNo
If yes, please explain:
Does your child have any learning disabilities?

YesNo
Any prescribed medications?

YesNo
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:

MonthDayYear
Date
Grade:
School:
Is your child under any medical/physical restrictions?

YesNo
If yes, check all that apply:

AsthmaDiabetesSeizuresHearing Loss
Is your child taking any medications?

YesNo
If Yes, please list:
Has your child been under a doctor's care or hospitalized within the last 3 years?

YesNo
If yes, please explain:
Is your child allergic to any medications, foods or insect stings?

YesNo
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:

MonthDayYear
Date
Photo Waiver Release
I do not grant the releasee permission to use photographs/videos in which my/my child's likeness appears
Signature

Clear
Date

MonthDayYear
Date
I hereby grant the releasee permission to use photographs/videos in any of the following:

Web-based PublicationsPrint AdvertisementsOrganization BulletinSocial Media
Age Of Consent

I am of legal ageI am a minor and represented by my parent or guardian
I hereby affirm that such release to the releasee does not constitute any form of compensation, including royalties arising from the photographs, to my benefit.

I understand and agree that photographs or videos in the possession of the releasee shall become the property of the releasee. The use and publication of the photographs however, shall conform to my rights as a subject of said photographs.

I hereby waive my right to inspect of approve the photographs or videos by which my likeness appears.

I hereby hold harmless, release, and forever discharge BlessedGirl from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
Signature

Clear
Date

MonthDayYear
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

Photo Waiver Release