Ladies with Purpose Mentoring Program Mentee Application

Ladies with Purpose Mentoring Program Mentee Application
PREFERRED SERVICES

Group MentoringIndividual Mentoring
YOUTH INFORMATION
Name

First NameLast Name
Grade
DOB
Nickname
School
Primary Address
Secondary Address
Youth Email
example@example.com
Youth Cell Phone
Youth Cell Phone
Youth Cell Phone
PARENT/ GUARDIAN INFORMATION
Name(s)
Email(s)
example@example.com
List all phone numbers where the parent/guardian can be reached (type: i.e. home, cell)
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
EMERGENCY CONTACT
Relation
Relation
Name
Relation
PARENTAL CONSENT
The undersigned does hereby give permission for my child
name)(“Participant”), to attend and participate in any Ladies with Purpose Mentoring Program activities, events, etc.

LIABILITY RELEASE: I, the undersigned, do hereby release, forever discharge and agree to hold harmless Ladies with Purpose Mentoring Program, its mentors and volunteers (collectively herein the program) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the mentoring program. I the parent or legal guardian of this participant hereby grants my permission for the participant to participate fully in Ladies with Purpose Mentoring Program activities, including trips in the community and away from site premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Ladies with Purpose Mentoring Program for any liability sustained by said Ladies with Purpose Mentoring Program as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize an adult of Ladies With Purpose Mentoring Program, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

EARLY RETURN HOME POLICY: Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation and responsibility.
TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by Ladies with Purpose Mentoring Program. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.
Signature of Parent/Guardian Date

Clear
Signature of Parent/Guardian Date

MonthDayYear
Date
MEDICAL INFORMATION
PRIMARY CARE PHYSICIAN
Name
Phones
Fax
Name of practice
Date of last Tetanus shot required

MonthDayYear
Date
INSURANCE INFORMATION
Medical Insurance Company
Phone
Policy/Group ID#
Policy Holder’s Name (please print)
MEDICATION:
List all medications the youth will take during any activities. This includes any prescription, non- prescription medications, herbal supplements and vitamins. Any participant under the age of 18 is required to give ALL MEDICATIONS to the mentor in their original containers with complete

dispensing instructions before the start of the event. Youth are not permitted to carry any prescription or non-prescription medication and will be sent home at the parent/guardian’s expense if they do.
Medication Name
Dose Treatment for
Example: Zyrtec
Take one pill daily in the morning with food

Over-the-Counter Medication Permission: Do you give permission for your child/youth to be given over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl).
Parent signature

No. Contact me or get medical help if my child has any minor medical concerns.
Parent signature

Clear
Ye s . I give permission to give my child approved over-the-counter medications as directed on an

Ye s . I give permission to give my child approved over-the-counter medications as directed on an
as needed basis to treat non-emergency medical conditions.
Parent Signature

Clear
MEDICAL CONDITIONS: Please answer in detail if applicable or write N/A. Attach additional pages

1. List any medical conditions (asthma, diabetes, epilepsy, etc:

2. List any allergies (drug/medicine, food, and/or environmental) and the severity and type of reaction:

3. Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know.
Ladies with Purpose Mentoring Program
Expectations
The following rules and guidelines are equally binding on adult leaders/chaperones and youth.
NON-NEGOTIABLE RULES
- Any participant failing to abide by these rules will be sent home immediately at personal/family expense.
- • Presence at and full participation in all group activities. • No sexual misconduct (defined as exposure, touching, or inappropriate reference to body areas normally covered by undergarments) • Smoking and the use of tobacco products are not allowed to, from, or during any trip. • Will not break any laws in the United States or any other country. • No fighting or physical force
GUIDELINES FOR LADIES WITH PURPOSE MENTORING PROGRAM
- Participants will be equally responsible for performing assigned tasks in a timely and cooperative manner. • Participants will be respectful, encouraging, and will maintain a positive attitude toward others at all times. • Participants will be respectful others property. • Participants will avoid the use of foul language, cursing, or any speech (including “humor”) which puts down, makes fun of, or stereotypes other persons or groups.
Youth Participant’s Statement: By signing this form, I pledge to follow the rules and guidelines printed above. I understand that I cannot participate in the activities unless this completed form is on file.
x

Clear
Parent/Guardian’s Statement: By signing this form, I agree to support the Ladies with Purpose Mentoring Program Expectations printed above, and will accept responsibility for the child’s return transportation should she break one of the non-negotiable rules.
x

Clear
Date

MonthDayYear
Date
Ladies with Purpose Mentoring Program
Photo Release Form
I agree that Ladies with Purpose Mentoring Program may photograph and record my child/dependent’s likeness and activities (Images) during activities. I grant the following rights to Ladies with Purpose Mentoring Program: permission to use and re-use, publish and re-publish, and modify or alter the Image(s) taken during the shoot. Use of the Images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the Internet, and worldwide in perpetuity for the purposes stated above.

I waive my right to inspect or approve any editorial text or copy that is used in connection with the Images and release and discharge Ladies with Purpose Mentoring Program from any and all claims arising out of use of the I mages for the purposes described above, including any claims for libel, invasion of privacy, or other tortuous act.

I have read the foregoing. I fully understand its contents, understand that this agreement does not expire, and confirm my agreement by signing below.
Child/Youth’s Name (print)
Signature

Clear
Parent/Guardian Name (print)
Signature

Clear
Ladies with Purpose Mentoring Program
Contact and Information Release
(To Be Completed by the Parent/Guardian)
Date

MonthDayYear
Date
Date

MonthDayYear
Date
I hereby grant permission for Ladies with Purpose Mentoring Program to make contact with my child and conduct a personal interview for the purposes of applying to be a mentee. Ladies with Purpose may also make contact with my child on school premises for the purposes of screening and interviewing as well as ongoing support of his/her participation in the mentoring program.

I authorize Ladies with Purpose to obtain any needed information regarding my child from his/her school’s staff, including academic and behavioral records and conversations with teachers, counselors, and other administrative staff.
Further, I understand that basic information about my child will be anonymously (without names) shared with a prospective mentor(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my and my child’s identity and other relevant information will be shared with the mentor to the extent it aids in facilitating a successful match.

Clear
Further, I understand that basic information about my child will be anonymously (without names) shared with a prospective mentor(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my and my child’s identity and other relevant information will be shared with the mentor to the extent it aids in facilitating a successful match.

MonthDayYear
Date
Parent/Guardian
Parent/Guardian Name
Phone Number
Address
City
Zip
Zip
Ladies with Purpose Mentoring Program
Please read this carefully before signing:

Ladies with Purpose Mentoring Program appreciates you and your child’s interest in her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their daughter to participate in the Ladies with Purpose Mentoring Program.

Please initial each of the following:
I give my informed consent and permission for my child to participate in the Ladies with
Purpose Mentoring Program and its related activities
I agree to have my child follow all mentoring program guidelines and understand that any
violation on my child’s part may result in suspension and/or termination of the mentoring relationship.
I hereby acknowledge that my child will be transported by her mentor and/or Ladies with
Purpose staff or representatives while participating in the Ladies with Purpose Mentoring Program, and that such transportation is voluntary and at her own risk.
I release the Ladies with Purpose Mentoring Program of all liability of injury, death, or other
damages to me, my child, family, estate, heirs, or assigns that may result from her participation in the program, including but not limited to transportation, and hold harmless any Ladies with Purpose Mentoring Program mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.
(optional) I agree to allow Ladies with Purpose to use any photographic image of my child taken
while participating in the mentoring program. These images may be used in promotions or other related marketing materials.

I understand I must return a completed application, and that any incomplete information will result in the delay of my application being processed:
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

Clear
Date

MonthDayYear
Date
Ladies with Purpose Mentoring Program Mentee Questionnaire
P lease briefly and to the best of your ability answer the following questions and attach it to your application.

1. How did you hear about the Mentoring Program? Why have you decided to apply? (For tutoring, advice, friendship, “big brother/big sister,” to learn about college life, or as someone to just hang out with?
2. What are the three biggest challenges that you deal with?
3. How do you see the Mentoring Program helping you deal with these challenges?
4. Please describe three things that you are good at?
5. What are you looking for in a Mentor? A good listener, active in sports, etc
6. What do you hope to gain from your mentor experience?
6. What do you hope to gain from your mentor experience?
7. Please list your interests, hobbies, and any other comments you wish to include!
8. Is there anything else you would like us to know about you that will help us make a good match?
Should be Empty:

Ladies with Purpose Mentoring Program Mentee Application

YOUTH INFORMATION

PARENT/ GUARDIAN INFORMATION

PARENTAL CONSENT

MEDICAL INFORMATION

PRIMARY CARE PHYSICIAN

INSURANCE INFORMATION

MEDICATION:

Medication Name

Dose Treatment for

Ladies with Purpose Mentoring Program

Expectations

NON-NEGOTIABLE RULES

GUIDELINES FOR LADIES WITH PURPOSE MENTORING PROGRAM

Ladies with Purpose Mentoring Program

Photo Release Form

Ladies with Purpose Mentoring Program

Contact and Information Release

Ladies with Purpose Mentoring Program

Ladies with Purpose Mentoring Program Mentee Questionnaire