I Am The Prize, Inc. Mentorship Experience Registration Form

I Am The Prize, Incorporated

Fall 2023 Mentorship Program
Student Name
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Name*
Student Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Student's Email*
example@example.com
Shirt Size (Please specify if Adult or Youth Size is needed)*
Grade*
Age*
YesNo
WhiteBlack/African AmericanNative AmericanDon't Know
Hispanic/LatinoNon-Hispanic/Latino
EnglishSpanishOther
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
E-mail*
example@example.com
Relationship to Student*
Single ParentMarriedDivorcedWidowed
G.E.D.High School DiplomaTechnical or Occupational DiplomaAssociate DegreeBachelor's DegreeMaster's DegreeDoctorate DegreeNone of the above
$10,000-$30,000$30,000-$50,000$50,000-$70,000$70,000-$100,000Other
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does the Student have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Please list any extracurricular activities member participates in?*
I Am The Prize, Inc.
Acknowledgments/Agreement

I affirm, by my signature below, that all information on this form is true and correct. I understand that the information provided may be verified. I understand that my child may be at risk for any accidental situations while being under the care of this program. I give my child permission to be under the supervision of all mentors within I Am The Prize Incorporated.
I give consentI do not give consent
Print Name*
Date

MonthDayYear
Date
I Am The Prize, Inc.
Media Release Authorization

AUTHORIZATION TO BE FEATURED IN PROMOTIONAL PUBLICATIONS, INFORMATIONAL/TRAINING/EDUCATIONAL INITIATIVES, AND/OR PRESENTATIONS.
I, hereby grant permission to I Am The Prize, Incorporated, for the above-named to be video/audio taped and/or featured in promotional publications, informational initiatives, training/educational initiatives, and/or presentations of the organization. These materials may include but are not limited to publications and electronic communications produced by I Am The Prize, Incorporated, and/or any of its funders, partners, affiliates, or supporting organizations.

This includes the use of photographs, voice, audiovisuals, and/or public/promotional appearances. The purposes of the publications, informational initiatives, training/educational initiatives, and presentations will be for the promotion of the organization and its services, for training/educational purposes, and for fundraising initiatives.

I (We) hereby agree to the reproduction and use of my (our) likeness and voice, which may be edited, altered, modified, and revised, for any of the purposes set forth above in all media anywhere in the world at any time without limitation.

I (We) hereby grant to I Am The Prize, Incorporated the right to use my (our) performance and/or voice and/or likeness for any of the purposes set forth above in all media anywhere in the world at any time without limitation.

I (We) release and discharge all designers, printers, publishers, producers, photographers, videographers, researchers, trainers, production teams, I Am The Prize, Incorporated, its agents, and employees from all liability claims, or demands in law or in equity arising from the use of such features, photographs, voice, audio/visual materials and/or public/promotional appearances.

I (We) authorize that a photocopy of this authorization may be considered as valid as the original. I understand that my agreement to participate in any of these activities is voluntary.

I also understand that I may revoke this authorization at any time, provided I notify the program in writing to this effect. A revocation has no effect on action previously taken.
Date*

MonthDayYear
Date
There is a financial commitment of $300.00 yearly to be a part of I Am The Prize, Inc. Payment plans and fundraising initiatives will help us cover the cost for each girl.

There is also a non-refundable fee of $25.00 for your application to be considered complete. Please make the payment below.

My Products

Application Fee

$25.00

Total

$0.00

Credit Card

Should be Empty:

I Am The Prize, Incorporated

Student Name

Credit Card