100 Black Men Mentee form

Mentee Register Form

100 BLACK MEN OF COLUMBUS GA
I hereby grant consent for my child to participate in the mentoring program of the 100 Black Men of Columbus GA, Inc(100 BMOC). Mentoring may include any event or activity sponsored by the 100 BMOC. Some events and activities may be held at an off-site location. Prior notification will be given. This form is intended to include permission for said student/mentee in elementary school, middle school, and high school.
STUDENT INFORMATION:
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Age*
School Grade level
Please choose one that apply to your student
Name of School*
Counselors name*

First NameLast Name
Counselors Number*

Area CodePhone Number
Medical Concerns
MENTOR INFORMATION:
Mentor (1)

First NameLast Name
Mentor (1) Email
example@example.com
Mentor (2)

First NameLast Name
Mentor (2) Email
example@example.com
Mentor Notes
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Parent Portal Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Emergency Phone Number

Area CodePhone Number
I agree to enroll my child with the 100 BMOC until high school graduation. However, I reserve the right to withdraw my child from the program by requesting withdrawal in writing. I further agree to provide access to the Muscogee County School District Parent Portal. I also grant the unrestricted right to use my child's name and likeness (photos) for all and any purpose in connection with the programs of the 100 BMOC. Waiver of Usability I (the Indemnitor/Parent/Guardian) agree to indemnify and hold harmless the 100 Black Men of Columbus Ga Inc. (the Indemnitee) from any claim, action, liability, loss, damage, or suit arising from the following: Any mentoring session/activity/event and transportation to and from any mentoring session/activity/event sponsored by the 100 Black Men of Columbus Georgia Inc. I also give permission for my child to receive first aid if needed.
Yes, my child has my permission to participate in the 100 Black Men Mentoring Program.

AgreeDisagree
Signature*

Clear
Date of Signature

MonthDayYear
Date
Should be Empty:

Mentee Register Form

STUDENT INFORMATION:

MENTOR INFORMATION:

PARENT/GUARDIAN INFORMATION: