Men 2 Be

I,Parent/Guardian , as Parent/Guardian(s) ofchild , understand the nature of the Men 2 Be Mentoring program as described in the Men 2 Be Mentoring Brochure and Fact Sheet and willingly request a mentor for my child. I understand that Men 2 Be Mentoring will not deny my child's participation in the program solely based on any one of the following statements

I consent to my child's participation in the Men 2 Be Mentoring program and give him/her my permission to participate;

I will do everything I can to help him/her meet the program requirements;

I will fully support my child's relationship with the Men 2 Be Mentor. Should I need to discipline my child, I agree that discipline would not automatically include denial of contact with the Mentor;

I hereby give consent for the Men 2 Be Mentoring Mentor Coordinator, Mentor or staff to obtain appropriate emergency medical or dental attention for my child, if such attention is required while I am unavailable or unable to be contacted;

I give my permission for Men 2 Be Mentoring Mentor Coordinator or staff to share and access information with other agencies and professional persons working with my child, including but not limited to, psychological, medical, and school/educational information, including grades, test results and attendance;

I agree to provide the Men 2 Be Mentoring Mentor Coordinator or staff with copies of my child's school report cards upon request;

I give my consent for the Men 2 Be Mentoring Mentor or the Mentor Coordinator to share information regarding my child's progress and the status of the match with referral or other agencies, as appropriate;

I give my permission for my child's name, likeness and speech in any audiotape, videotape, filmed photograph made at any Men 2 Be Mentoring activities for public relations or fundraising purposes of Men 2 Be Mentoring. I also give consent for any printed materials, artwork, stories, or quotes from my child to be used for public relations or fundraising purposes;

I give my permission to the Men 2 Be Mentoring mentor and/or Mentor Coordinator or staff to visit, pick up, or transport my child for activities and events;

I give my permission to the Men 2 Be Mentoring Mentor and/or Mentor Coordinator or staff tovisit, pick up and be an advocate for my child at his or her school;

Does the child have any allergies?

If yes, please list here allergies

In effort to help our children in the program, there are some things that we will be expecting from the parents and the children and the mentors of Men2Be.As a mentor, we will be expecting the following. 1. Communicate your availability as needed. 2. Be a positive role model for the kids. 3. Learn to understand your role as a mentor. 4. Seek improvement daily to help become a better mentor and leader in the community. Mentor sign here

As a mentee and parent, we will be expecting the following. 1. Attend meetings on the regular, if not let us know ahead of time as we are planning for everyone to be there for every meeting. Parents we are asking for you to let us know ahead of time if your child isn’t going to make it. 2. Come prepared to learn and have a good time. 3. Be active and attentive while in meetings 4. Be respectful and ask as many questions as needed to get comfortable with your mentors. 5. Strive to do what is right at all time, you are apart of Men2Be and its not just during our meetings. 6. Be willing child to learn and try new things. Mentee sign here

I understand that my child will be participating in various one-to-one activities with a volunteer mentor, and that he/she will be under that volunteer's supervision during those activities. I release Men 2 Be Mentoring, its officers, agents, employees and volunteers from any and all liability, claims, demands or causes of action whatsoever that I may have as Parent/Guardian of this youth, for damage, loss or injury to him/her which may occur while participating in any of the activities contemplated by this Agreement, whether caused by the negligence of Men 2 Be Mentoring, its officers, agents, servants, or employees, or by the negligence of the Men 2 Be Mentoring volunteer, or otherwise. I understand that my child's participation in Men 2 Be Mentoring sponsored activities and specific activities with his/her mentor is voluntary. By my signature below, I hereby acknowledge that I have read and understand this document and the items contained therein, and that I have received a copy of this document for my records.

Signature of Parent/Guardian
First Name   Last Name     Date   Date     Area Code   Phone Number

Printed Name Parent/Guardian   First Name   Last Name

Signature of Men 2 Be Staff Member   First Name   Last Name   Date   Date

Printed Name of Men 2 Be Staff Member   First Name   Last Name

I give consent for the Mentor or Men 2 Be Mentoring representative to obtain appropriate emergency medical or dental attention for Mentee), should such attention be required while I am unavailable for contact.

Name of Primary Care Physican     First Name   Last Name   Phone   Area Code   Phone Number

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM
AWARE THAT THIS IS A
RELEASE OF LIABILITY AND A CONTRACT BETWEEN ONE-ON-ONE PARTNERS AND/OR ITS
AFFILIATED
ORGANIZATIONS AND MYSELF AND HAVE SIGNED IT OF MY OWN FREE WILL. THIS CONTRACT
IS IN EFFECT UNTIL CANCELLED IN WRITING.

Signature of Parent/Guardian
First Name   Last Name

Witness Signature
First Name   Last Name

Date   Date

Parent's Email Address*

example@example.com

Men 2 Be

PLEASE Make the Correct Selection Below