The House of Darla Mentor/Membership Registration Form

Registration

Complete the form below to sign up and be contacted for our mentorship, membership services, programs, events, and more. If you need help with this form and/or have any questions please feel free to contact us: at 203-981-1681 , Info@TheHouseOfDarla.org( in the subject write: application help), and/or via our contact form at www.TheHouseOfDarla.org. REFERRALS FROM AN AGENCY REQUIRE REFERRAL FORM IN ADDITION
Parent/ Guardian*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student info *

First NameLast Name
Birth Date

MonthDayYear
Name Of School*
Current Grade*
Current Age*
Gender*

FemaleMalePrefer not to answerOther
If you chose other please use the box below
In your own words please describe your child ( i.e. shy, outgoing, emotional, likes or dislikes etc) : *
T Shirt Size?*

SmallMediumLargeXLXXLXXXL
Race*

Black/ African AmericanLatinoWhiteNative American/AlaskanAsianTwo or more racesOtherN/A
Interested In:*

Life Skills: everything from how to create and prepare budget-friendly meals, laundry, couponing, how to change a tire & oil, interviews, resumes, and more.Jr.Chef: Students learn how to create budget-friendly meals, and snacks, while competing, having fun, and learning the importance of etiquette and hygiene.Clubhouse(after-school mentor program): A Safe Space for students to participate in mentoring clubs, get homework done, access tutors, and more.SWAG: Young Boss: Students learn how to start and run their very own businesses, create products and merchandise, job readiness, the difference between needs and wants, financial literacy, and participate in workshops, and activities while having fun.Fit, Fun & Yum: For students and athletes, who are looking to learn how to set and achieve goals, find discipline and work up sweat-burning calories in 7-minute fitness challenges, yoga, and more while having fun, learning health equity, and creating and enjoying healthy snacks and meals.Book club: Promoting and encouraging literacy and reading comprehension through book clubs, reading, audiobooks, and more. Students enjoy snacks and beveragesPeer Group: Learn conflict resolution skills, and engage in discussions, activities, and bonding.Legacy: Leadership, volunteering and giving backWeekend Programming: Activities, and groups held on the weekendTutoring: Students who can benefit from additional supportMentor: Students who can benefit from one-to-one and group mentoringSports Coach: Help support and train in sports and conditioning, leadership, health and wellness, and more.Cohorts ( 4, 6, 8 , 12 week programs and activities)TSS ( services)CBLS ( services)SS( Services)Other
Where did you hear about us?*

A Friend or colleaugeGoogleSocial MediaNews ArticleOther
If you chose other or social media please enter Who and/or What
Membership Type Interested (Select all that apply)*

MentoringAfter-School ProgrammingBefore School ProgrammingWeekend ProgrammingHoliday (school vacation) ProgrammingTutoringSports CoachingOther
Interest (Select all that apply)*

Community EventsFamily NightsActivities for AdultsWorkshops for parents ( parent workshops )Coaching for adults( accountability, inspiration, motivation, goals, etc)Program Cohorts ( programs that last for 5-6 weeks, 6-8 weeks etc)OtherN/A
If you entered Other for interests:
I'm interested in programming/workshops etc for (select all that apply)*

MyselfMy childA family memberA Menteemy organizationAt risk youthsomeone I knowOther
Select all that apply*

I would like to donateI would like to sponsorI would like to supportI would like to VolunteerI would like to serve on a parent/Organization committeeOtherN/a
Would Your Child/youth Like to be in a club with a friend

YesNoN/A
If yes, Name and Age of Friend(s)
Does Your Child/ youth Have Any Allergies*

YesNo
If yes please list, including any food or drug allergies.*
Does your child/youth have any medical conditions? If no please enter N/A**
Does your child/youth require any medication? If yes, please list these medications. (we cannot administer medication, please come to the location to administer. ) If no please enter N/A**
Do you give your child/youth permission to walk to programming?*

YesNo
Do you give your child/youth permission to walk home from programming?*

YesNo
Do you give your child/youth permission to take public transportation, home from programming ( ie. City Bus, uber, Lyft) ?*

YesNoYes Only Bus
Preferred way to contact*

PhoneEmailTextAny
Please list the people authorized to pick up your child/youth. In addition to any other pickup drop-off information. If not applicable please enter N/A**
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
We are always interested in feedback, use this box as a free space to comment on needs, suggestions, words of encouragement, things you'd like to see, ways we can grow, support, excitement, or whatever else you believe we should know. and/or can help.
Mentee/Membership Rules

Club/Organization Rules and Guidelines
1. Code of Conduct:

1.1 All Mentees/Members are expected to conduct themselves in a respectful and responsible manner at all times.

1.2 Mentees/Members must comply with all applicable laws and regulations.

2. Prohibited Activities:

2.1 Smoking/Vaping: Smoking/Vaping is strictly prohibited in all club/organization premises and during club/organization activities.

2.2 Drinking: The consumption of alcohol or any illegal substances is strictly prohibited during club/organization activities.

2.3 Verbal or Physical Aggression: Verbal or physical aggression, including harassment, bullying, or any form of violence, will not be tolerated.

2.4 Being Under the Influence: Members must not attend club/organization activities while under the influence of alcohol, drugs, or any impairing substances.

3. Attendance and Participation:

3.1 Mentees/Members are expected to attend club/organization activities/ regularly when applicable and be actively engaged in the club/organization's objectives and initiatives.

3.2 If a Mentees/Members cannot attend a scheduled activity, day, or event, they should notify the club/organization/ Mentor in advance, if possible.

4. Respect for Others:

4.1 Mentees/Members should show respect towards fellow members , club/organization leaders, guests, and any individuals encountered during club/organization/Mentoring activities when applicable.

4.2 Discrimination, harassment, or any form of disrespectful behavior based on race, ethnicity, gender, sexual orientation, religion, or any other protected characteristic will not be tolerated.

5. Confidentiality:

5.1when applicable must respect the confidentiality of any sensitive or private information shared within the club/organization.

5.2 Sharing personal information or any club/organization-related information without appropriate consent is strictly prohibited.

6. Compliance with Club/Organization Policies:

6.1 Mentees/Members are required to comply with all club/organization policies and guidelines, including those related to safety, equipment usage, and any specific rules pertaining to club/organization activities .

7. Consequences for Violations:

7.1 Violation of any of these rules and guidelines may result in disciplinary actions, including but not limited to warnings, probation, suspension, or termination of club/organization membership.

8. Amendments to the Rules and Guidelines:

8.1 These rules and guidelines may be amended or updated as necessary by the club/organization, and members will be notified of any changes.

By participating in the Mentorship/club/organization and signing below, I acknowledge that I have read, understood, and agree to abide by these rules and guidelines.
We believe in there not being a barrier to students and youth recieving suport. With this being said, Although Mentorship programs are $150 for the school year* . We have Full and Partial Scholarships Available, and will do our best to work with parents and families. Sliding scales, payment plans, sponsors, fee waivers, and scholarships. Please contact us at 203-981-1681.

Mentorship/Membership Comes with: 2 program Shirts*, HODxSWAG BAG KIT, MENTORING* , ACCESS TO DROP INS* and THE SPACE: A FRIDAY NIGHT SAFE ZONE for Students*2024 , PRIORITY REGISTRATION, ACTIVITIES, COHORTS & DISCOUNTS, DISCOUNTS ON MERCHANDISE, CONCESSION, AND SUMMER PROGAMMING, PRIORITY REGISTRATION ACCESS TO FAMILY /COMMUNITY DAY EVENT(s), PARENT WORSKSHOPS and EVENTS,FOR THE CALENDAR YEAR 2023-2024. 2HOURS of PREFERED INTEREST TIME* A MONTH TO CULTIVATE CRAFTS, SKILLS AND HOBBIES.
Terms & Conditions*

I have read, understood, and accepted the rules for mentor/ membership.I have read, understood, and accept the terms and conditions listed on the website ( www.TheHouseOfDarla.orgI understand, and acknowledge that members have to apply
Further info*

I have read, understood, and accepted the Terms and Conditions and PRIVACY POLICY for application for mentorship/ membership. In addition, I understand and acknowledge that parents and members have to apply and this is one of the first steps in the application process.
Once you submit your application, we will contact you shortly to complete your membership application.

Thank you!
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Registration

Mentee/Membership Rules