Consent Form

Cultivating Leaders Mentoring Program

Parent/Guardian Consent and Liability Release Form
Parent/Guardian Consent and Liability Release Form

I give my consent for the Youth Mentor Program at Cultivating Leaders, Inc. to match my child with a mentor of the organization. I will also give consent for my child to participate in all Cultivating Leaders Mentor activities; including all organized activities and transportation. In consideration of the advantages of participation in Cultivating Leaders Youth Mentor Program, the undersigned agrees that Cultivating Leaders Mentors and its employees shall be released and exempt from any liability for damages for bodily injuries or property damages that may occur as a result of participation in the Youth Mentoring Program, except to the extent of insurance liability provided by law.
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Home Number

Area CodePhone Number
Mobile Number*

Area CodePhone Number
Work Number

Area CodePhone Number
Relationship to Child*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Emergency Contact Email*
example@example.com
Please tell us why you think your child would benefit from the program and list anything of interest? *
Required Signature
Parent / Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Cultivating Leaders Mentoring Program