2022 Bee the Difference Mentoring App

2022 Mentorship Application Form (Girls 13-18)

Some Preteens (age 12) may be considered
Thanks for taking interest in our Mentoring program! Please complete the application entirely and sign wavier below to have your child considered for our 2022 (Mar-Oct) Program. We will contact you to discuss enrollment.

By providing monthly check-ins and once a month face-to-face group sessions, our mission is to provide each young person with the insight, guidance, and empowerment needed to have a sense of optimism for the future.

By utilizing Christain values and Biblical perspective...It's our hope that these young ladies will be able to make a difference in their classrooms, homes, communities and lives.

If you have any questions about our program or the application, please don't hesitate to email at beementoring@yahoo.com or call 601-392-2498
Member Full Name *
Preferred Name
Nickname
School *
Grade *
Birth date *

Month Day Year
Age *
T-Shirt Size

Youth S Youth M Youth L Adult S Adult M Adult L Adult XL Adult 2X None- Returning Mentee Only
T-Shirt Cost

Youth S-L $8 Adult S-L $10 Adult XL $12

Caregiver's Name *
Relationship to Child *
Address *
Primary Number *

Area Code Phone Number
Is it okay to send texts updates? *

Yes No
Caregiver's Email *
example@example.com
Other Caregiver/ Emergency Contact
Name
Relationship to Child
Other contact's phone

Area Code Phone Number
Pick Up Authorization
Please note that Only authorized cargivers/Emergency contacts may pick the child/ren up from Bee the Difference unless there's a written authorization stating otherwise. Picture I.D maybe asked before pick ups or drop offs.
MENTORING CLUB MEDICAL RELEASE FORM
PLEASE NOTE: This Medical Release Form will be used ONLY as necessary in the circumstances. Every reasonable effort will be made to first notify a caregiver/Emergency contact listed above prior to the use of this Medical Release Form.
Preferred Hospital or Clinic *
Phone Number

Area Code Phone Number
Address
My child have the following allergies: Type N/A if None: *
My child is receiving medication or has a condition that may affect behavior or increase risks: Type N/A if None *
By signing below, I hereby give permission for my child to attend and participate in the Activities. I specifically authorize Bee the Difference Mentoring Program to provide for, and arrange in my place, necessary medical care.
MENTORING CLUB PARTICIPATION
I hereby give permission for my child to travel and participate in offsite events. *Advanced Notification will be given to parent for all off-site events.

YES NO
I hereby give permission for my child to receive check-ins from a trusted mentor (via phone, text, social media etc.)

YES NO
I hereby give permission for my child's picture to be used for Bee the Difference promotion and advertising, including, but not limited to, brochures, newspaper or magazine articles, and website

YES NO

PLEASE NOTE: Participating in any of our activities (especially face-to-face) involve certain inherent risks. Regardless of the care taken, social distancing, etc. While Bee the Difference will use care and try our best to take safety measures during COVID-19 and other circumstances, it is impossible to guarantee the safety of all participants.

Therefore, by signing below you agree to waive, release, and discharge Bee the Difference, it staff, members, and volunteers from any and all liability, including but not limited to, liability arising from the negligence of any sickness, illness, injury, damage, losses, or any other damage or actions of any kind which may affect or impact your child in any way arising from her participation.
Caregiver Signature *

Clear
Date *

Month Day Year
Date
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2022 Mentorship Application Form (Girls 13-18)

Pick Up Authorization

MENTORING CLUB MEDICAL RELEASE FORM

MENTORING CLUB PARTICIPATION