FFM Student Application

Date*

Date

1. Participant Your Name*

First NameLast Name

2. Parent/Guardian Name*

First NameLast Name

3. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

4. Parent/Guardian Email*

example@example.com

5. Parent/Guardian Phone Number*

Format: (000) 000-0000.

6. Participant Birthdate*

Date

7. Participate Age*

8. Participant Grade*

9. How long have you been in the program?*

10. Please select the school your child or student currently attends. (Focus Fairies Mentoring offers school-based programming exclusively for students who are currently enrolled at the schools listed below.⚠️ If your child or student does NOT attend one of these partner schools, they are not eligible to enroll in programming at that location).*

11. If your child or student does not attend one of our partner schools above, please select the community base programming you are interested in:*

Oakwood Shore Community CenterMarshall Fields Garden Community CenterNot Applicable

12. Are you interested in our Tween Girls Club (girls ages 9-13)? The Tween Girls Club is a vibrant and supportive community designed for girls aged 9 to 13. Our program is dedicated to fostering a safe and intimate space where girls can freely express their voices, manage their feelings, and engage in meaningful activities that challenge societal norms and promote personal growth.*

YesNo

12. Which race or ethnicity best describes the participant?*

13. Please check the additional support services you are interested in?*

Mental Health Support (Individual or Family Therapy)Parent/Care-Giver Resources/SupportN/A

Photographic & Volunteer Release

I hereby grant permission to the rights of my child(ren) image, likeness, and sound of my voice as recorded on audio or videotape without payment or any other consideration. I understand that my child(ren) image may be edited, copied, exhibited, published, or distributed, and I waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

Photographic, audio, or video recordings may be used for the following purposes:
• conference presentations
• educational presentations or courses
• informational presentations
• online educational courses
• educational videos

By signing this release, I understand that this permission signifies that photographic or video recordings of my child(ren) may be electronically displayed via the Internet or in a public educational setting.
I will be consulted about using the photographs or video recording for any purpose other than those
listed above. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. This release applies only to photographic, audio, or video recordings collected as part of the sessions listed in this document.

By signing this form, I acknowledge that I have completely read and fully understand the above release and
agree to be bound. I hereby release and agree to claims against any person or organization utilizing this material for educational purposes.

I hereby grant permission to the rights of my child(ren) image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration*

YesNo

Parent of Candidate Signature*

Student Application

Focus Fairies Mentoring offers programs in partnership with select Chicago Public Schools and community-based locations. Please select the option that best describes your child’s or student current school or program interest.