SISTER LINKAGE MENTORING PROGRAM

FIRST MIDDLE LAST

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

(PLEASE NOTE: All correspendence will be sent to the above address unless otherwise specified.

SCHOOL NAME

GRADE LEVEL

PARENT/GUARDIAN NAME

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

CELL/PRIMARY PHONE

I (We) have read the description of the Sister Linkage mentoring and enrichment training program presented by EASTON BANKS LEARNING & LIFE CENTER, INC. and find it acceptable for my (our) child’s participation. In addition, my (our) child has permission to participate in field trips off the site identified for SLMP activities and workshops. Recognizing the educational aspiration, personal and social development benefits of the Sister Linkage program to my (our) child, and acknowledging that participation is completely voluntary. I (We) the parent(s)/guardian(s), do hereby agree to Release Idemnity and hold harmless EASTON BANKS LEARNING & LIFE CENTER (EBLLC, INC), for any loss, injury, or damage resulting directly or indirectly from the participation in the Sister Linkage Mentoring Program.

Parent's Signature

Clear

I, blanks the parent of blank, pledge that my child will attend all scheduled virtual program meetings and activities. I will make program administration aware of any changes that could affect my child's participation in the program. I will also be committed to being actively involved in this life changing program for the success of my child.

I understand that there is a program fee of $150 due at the time of registration. This fee will cover program supplies (i.e. program shirt, program handbook and journal, etc.) and other administrative costs. I, further understand that I will be required to give a small monetary contribution for my child to participate in certain activities and field trips (when applicable).

I have been made aware that program scholarships are available to families who can provide proof that they have a financial need. Additionally, I have been informed of the program requirements and do hereby give my child permission to participate in the mentoring and enrichment program offered by EASTON BANKS LEARNING & LIFE CENTER, INC. (EBLLC, INC.).

Parent Signature

Clear

I, pledge to attend all scheduled program virtual meetings and activities with a positive attitude. I will make every effort in accordance to the program description to make the necessary strives in my life for the success in my life that I desire. For any given reason if changes should occur in my life that could affect my participation, program administration will be immediately made aware of those changes.

I have been made aware of the program requirements and do hereby agree to adhere to those terms. I further understand that at any time this agreement is not maintained by either party, this agreement may be dissolved without further notice.

Participant's Signature

Clear

I, the undersigned, do hereby grant or deny permission to EASTON BANKS LEARNING & LIFE CENTER, INC. to use the image of my child, blanks as marked by my selection(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletter, videos, and digital images such as those on EASTON BANKS LEARNING & LIFE CENTER's (EBLLC, INC.) website.

Select all that apply:

Deny permission to use my child’s image at all.Grant permission to use my child’s image in the following ways mark all that apply):

Limited usage: I want my child’s image used within Easton Banks Learning & Life Center, Inc. setting only not in the larger community.

Limited usage: I want my child’s image used for educational materials only not marketing. This could be either within Easton Banks Learning & Life Center, Inc. or in the larger community. One example of this could be videos in parent education classes.Limited usage: I want my child’s image used on printed materials only no digital or video use).Unrestricted usage: I give unrestricted permission for my child’s image to be used in print, video, and digital media. I agree that these images may be used by EASTON BANKS LEARNING & LIFE CENTER, INC. for a variety of purposes and that these images may be used without further notifying me. I do understand that the child's last name will not be used in conjunction with any print, video or digital images.

Parent Signature

Clear

Recommender's Name:

Please have the person mentioned above to forward a brief description of how they know you. Please ensure that they include the following information. (Please indicate student’s name, behavior, length of association, etc.) Recommendations cannot be from relatives.

All recommendations should be sent to the attention of Dr. Bessie Stewart-Banks via email to: dr.bessie@ebllcinc.com

Thank you for allowing us to help you in the transformation of your daughter's goals and aspirations in life!

Program Application Fee

USD

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

SISTER LINKAGE MENTORING PROGRAM

A Mentoring & Enrichment Program

PARTICIPANT'S NAME:

FORM OF CONSENT (Signature Required)

PARENT RELEASE FORM

RECOMMENDATION FORM