Youth Mentoring Registration Form

  • Youth Mentoring Registration Form

    Fill out the form carefully for registration. Youth Mentoring-CCDN has 2 youth mentoring programs. Precious Pearls of Promise (11-18 young ladies) and Diamonds in the Rough (11-18 young men).  Mentees meet 1st and 3rd Saturdays 9:00 AM-2:00 PM.  
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  • Program of Interest (Check All that Apply)
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  • Education and Behavioral Analysis

  • Is youth currently enrolled in school?
  • If you answered "YES" to the question above, please indicate which school level youth is enrolled in.
  • Is youth currently receiving special education services such as 504 plan, 509 plan, IEP plan, or ADA accommodations?
  • Does youth have one or more than one of the following mood disorders, behavior disorders, attention disorders, etc.?
  • Is youth or family receiving counseling services?
  • If you answered "NO", do you need or would you like to receive counseling services?

  • Emergency Persons/Emergency Contacts/Medical Information

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  • In case of emergency do we have permission to obtain medical attention for you/youth.

  • NOTE: Please be advised that CCDN will require a copy of the insurance card on file for emergency purposes. 

  • Are there any medical conditions CCDN need to be aware of?

  • Parent Consent and Certification

  • I, the undersigned, being the parent or legal guardian of the child named above, do hereby consent to the participation of my child in all activities conducted by Community Care Development
  • TRANSPORTATION RELEASE Applies to students only I give permission for my youth to be transported to and from, Community Care Development Network sponsored activities in a church, rental, or private vehicle. I understand that parents are responsible for picking students up from the main facility by the designated pick up time.
  • DISCIPLINE RELEASE Applies to students only in the event of misconduct, I authorize the staff to send my student home at my expense. Continued misconduct or disciplinary challenges from youth(s) will result in dismissal from the program. If youth is involved with disciplinary action which resulted from juvenile court, probation officer will be notified.
  • INSURANCE RELEASE Applies to all traveling I realize the Community Care Development Network’s insurance begins where the individual health and accident policy terminates. It is only valid when all other insurance has been extended to its limits.
  • PHOTOGRAPHY RELEASE I grant to Community Care Development Network the right to take photographs of me and my property in connection with the above-identified subject. I authorize Community Care Development Network its assigns and transference to copyright, use and publish the same in print and/or electronically. I agree that Community Care Development Network may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as news, publicity, illustration, advertising, Social Media, and Web content.
  • GENERAL RELEASE Applies to all traveling The undersigned or a member of the immediate family of the undersigned realizes that the participant may incur personal injury or bodily damage while participating in such activities, and acknowledge that the Community Care Development Network, it’s officers, directors, employees, agents, or any other parties volunteering on behalf of the organization, shall be held harmless from all actions, claims, costs, expenses or damages of any kind, growing out of or related to any activities of the organization. The undersigned or a member of the immediate family of the undersigned further acknowledge this is a full and complete release for all injuries and damages which the participant may sustain as a result of participating in any activity.
  • SOCIAL MEDIA Applies to involvement and engagement on Social Media platforms including Youth Mentoring Private Groups. The undersigned or a member of the immediate family of the undersigned realizes that there is participation on Social Media during the week and virtual participation via Zoom or Google Meets. I acknowledge that the Community Care Development Network, it’s officers, directors, employees, agents, or any other parties volunteering on behalf of the organization, shall be held harmless from all actions, claims, costs, expenses or damages of any kind, growing out of or related to any activities of the organization. The undersigned or a member of the immediate family of the undersigned further acknowledge this is a full and complete release for all liability, injuries, and damages which the participant may sustain as a result of participating in any activity.
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  • NOTE: Any persons designated as an emergency contact or pick up person will be required to show identification prior to picking up the youth.  Parents, please be sure to let them know  A phone call is REQUIRED if there are any changes in pickup person. 

  • I certify that I am a parent/legal guardian of the youth listed in this application.  I give permission for the youth listed in this application to participate in Community Care Development Network programs, services, and sponsored events and activities.  I have read and understood all of the releases above:

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