Father Figures Mentoring Intake form

Form
Date

MonthDayYear
Date
Youth's Name

First NameLast Name
Youth's Age and Date of Birth
Name of School
Current grade or Last Grade Attended
Parent/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Contact Name if Other Than Parent
Emergency Contact Phone Number

Youth's Physician name and Phone Number
Why do you/your child want to participate in a mentoring program?
What are your expectations of the mentoring program?
Describe your child's school performance.
Is your child currently having problems either at home or school?
To your knowledge has your child experienced any traumatic events you would like to disclose?
Does your child have any health or medical issues the program should be aware of? Prescribed medications ?
You as the mentees parent knows them best, what would you like us to know about your child?
Is your child available to meet with their mentor on a regular basis? Please explain any activities that may cause a conflict with participation.
We appreciate you and your child's interest in him becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their son to participate in the Father Figures mentoring program.

Please be advised in the event medical assistance is needed while your child is participating in the program they will be transported to the nearest medical facility that will be able to render the services necessary.
I give my permission and informed consent for my child to participate in the Father Figures Mentorship program and related activities.

YesNo
I hereby acknowledge that my child may be transported by Father Figures Mentoring and/or his mentor for participation in the program, and such transportation is voluntary.

YesNo
I release Father Figures Mentorship and Transitional Services Inc. of all liability of injury, death, or damages to me, my child, family, estate, heirs, or assigns that may result from his participation in the program, including but not limited to transportation. I hold harmless any mentor, program staff, or other representatives, both collectively and individually, of amy injury, physical or emotional, other than where gross negligence has been determined.

Agreed
Should be Empty:

Form