Mentorship Student Signup

Student Name*

First NameLast Name

Student Date of Birth*

Date

Gender*

School*

If you selected Other for the 'School Answer Field', please indicate the name of the school below.

Grade*

Parent Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Consent Form
The Bethany Center for Youth Mentorship is requesting your permission for your child’s general participation in the mentorship program and the release of information for monitoring your child’s attendance, and behavior. Please sign this form below granting permission for your child’s participation in the Bethany Center for Mentorship program.

I grant permission for my child to participate in the Bethany Center for Mentorship program. I authorize all of the following:

1. Participation in activities specified in the student contract such as instruction, tutoring, spiritual, and enrichment activities. Interviews, tests, attendance reports, and questionnaires for student or project evaluation purposes.

2. Release of confidential information to the Bethany Center for Mentorship (i.e. interviews; school academic, behavior, attendance, & IEP/Accommodations records).

3. Media coverage (published photographs or videos in newspapers, television, radio, social media, or web-sites).

4. Travel authorization for child to be transported to and from mentorship program campus, fieldtrips, appointments, meetings, and other activities. (Parent will be notified beforehand of transportation taking place).

5. Emergency medical or surgical treatment from a local hospital, or by any licensed health care professional in the event of illness, accident, or other emergency.

I fully understand, that in participating in the activities of the Bethany Church’s Center for Youth Mentorship program on behalf of myself, my spouse, my family members and my child(ren), we are participating in a program that carries certain risks and/or dangers. I personally assume, on behalf of myself, my spouse, my family members and my child(ren), all risk in connection with said activities for any harm, injury or damages that may befall myself, my spouse, my family members and my child(ren) participating and or volunteering in in the Bethany Center for Youth Mentorship Program whether foreseen or unforeseen, and I still wish to proceed.

In participating in the Bethany Church’s Center for Youth Mentorship sponsored activities, I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Bethany Church from any and all claims, demands, or cause of actions, which are in any way connected with these activities on behalf of myself, my spouse, my family members, and my child(ren). I hereby, agree to waive, release discharge and hold harmless Bethany Church, it’s staff, agents, representatives, and volunteers, from any and all liability, acts, causes of actions, claims, demands, personal injury, death, and other claims whatsoever arising out of, or in any way connected with myself, my spouse, my child(ren) and/or heirs, executors, administrators, guardians, successor, or assigns by participating in the Bethany Church’s Center for Youth Mentorship program activities. I warrant that I have read this agreement and fully understand it and that I have signed it of my own free will and accord without reliance on any representation of any kind or character not expressed or set forth herein. *

Indicated below are any specific activities in which I do not wish my child to participate:

Signature*