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  • Men 2 Be

    Parent/Guardian Permission Form
  • I, , as Parent/Guardian(s) of , 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

  • PLEASE Make the Correct Selection Below

  • If yes, please list here      

  • Clear
  • Clear
  • 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  
             Date   Pick a Date              

    Printed Name Parent/Guardian        

    Signature of Men 2 Be Staff Member         Date   Pick a Date   

    Printed Name of Men 2 Be Staff Member         

  • 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           Phone         


    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   
          

    Witness Signature   
          

    Date   Pick a Date   

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