LEAD Mentor Application

LEAD Returning Mentor Application
Name

First NameLast Name
Company
Phone (cell)
Please enter a valid phone number.
Phone (work)
Please enter a valid phone number.
Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Campus?*
If you need a new Polo shirt, please add the size below.
If you need a new button down/long sleeve shirt, please add the size below.
Do you need a new name tag?

YesNo
Have you ever been in trouble with the law?
If yes, please explain.
What businesses would you like to visit with your mentees?

PHOTO/VIDEO RELEASE
I,First Name*   Last Name*, ("Participant") hereby grants permission to the Greater Waco chamber of Commerce and its agents, officers, members, affiliates, providers, sponsors, contributors, volunteers, independent contractors, servants and employees, including, without limitation, individuals or entities involved in print, publication, television, broadcast, or video media ("Chamber"), to photograph me, to video me and/or record my voice and use my picture, photograph, video, silhouette and other reproductions of my physical likeness and sound ("Physical Likeness") in any way the Chamber sees fit, forever and throughout the world, for the limited distribution, advertising, promotion, exhibition and exploitation of greater Waco through media in all forms and for all purposes, through any method or device now known hereafter devised in which the same may be used, and/or incorporated and/or exploited and the Chamber makes no representations as to the use or distribution of the Participants Physical Likeness. Participant grants to the Chamber all of the Participant's rights to any and all of the photographs, videos, silhouettes and any other reproductions of my Physical Likeness taken by the Chamber.
Participant, and on behalf of my heirs, successors, and assigns, agree that I will not assert or maintain against Chamber, its successors, assigns, affiliates and licensees, any claim, suit or demand of any kind or nature whatsoever including but not limited to, claims for compensation, defamation, those grounded upon invasion of privacy, rights of publicity or other civil rights, or other infringements or violations or personal or property rights of any sort whatsoever, or for any other reason in connection with the authorized use of my Physical Likeness for any purpose as herein provided. I hereby release Chamber, its successors, assigns and licenses, and each of them, from and against any and all legal claims, liabilities, demands, actions, causes of action(s), costs and expenses whatsoever, at law or in equity, known or unknown, anticipated or unanticipated, which I had ever had, now have or may, shall hereafter have by reason, matter, cause or thing arising out of Chamber's use of my Physical Likeness as herein provided.
I affirm that neither I, nor anyone acting for me, gave or agreed to give anything of value to any of Chamber's employees or any representative of any television station, network or production entity for arranging the use of my Physical Likeness as set forth herein.
I have read the foregoing and fully understand the meaning and effect thereof and, intending to be legally bound, I have signed this release on   Date   2025.
Signature*
First Name*   Last Name*
Street Address   Address Line 2   City   State   Zip
Area Code   Phone Number

RELEASE, AGREEMENT NOT TO SUE AND INDEMNITY AGREEMENT
First Name*   Last Name*
Street Address   Address Line 2   City   State   Zip
Area Code   Phone Number (Day)
Area Code   Phone Number(Night)
Area Code   Phone Number (Mobile)
EMERGENCY CONTACT
First Name   Last Name
Area Code   Phone Number
The undersigned voluntarily agrees to participate as a mentor in the LEAD Program. The undersigned voluntarily signs this document as consideration for the undersigned’s participation in the LEAD Program and for the undersigned’s benefit of developing business leader-student relationships within the Waco Community as a mentor in the LEAD Program.
THE UNDERSIGNED HEREBY VOLUNTARILY ASSUMES RESPONSIBILITY FOR, AND RELEASES, WAIVES, ACQUITS, FOREVER DISCHARGES, AGREES TO INDEMNIFY, DEFEND, SAVE, HOLD HARMLESS AND NOT TO SUE THE WACO CHAMBER OF COMMERCE, ITS AGENTS, INDEPENDENT CONTRACTORS, MEMBERS, AFFILIATES, PROVIDERS, ASSOCIATES, SPONSORS, CONTRIBUTORS, VOLUNTEERS AND EMPLOYEES, ON THE ACCOUNT OF, ANY AND ALL LIABILITY, DEMANDS, LOSSES, EXPENSES, CLAIMS, OR CAUSES OF ACTION (COLLECTIVELY, THE “CLAIMS”), FOR PROPERTY DAMAGE, PERSONAL INJURY, ILLNESS, DAMAGE OF ANY KIND, OR DEATH, AS WELL AS ANY AND ALL ATTORNEYS’ FEES, COSTS AND OTHER EXPENSES INCURRED BY THE WACO CHAMBER OF COMMERCE, ARISING OUT OF, ATTRIBUTED TO, OR CAUSED OR ALLEGED TO HAVE BEEN CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE (SOLE, JOINT, CONCURRENT, ACTIVE, OR PASSIVE), GROSS NEGLIGENCE, INTENTIONAL CONDUCT, OR STRICT LIABILITY OF THE WACO CHAMBER OF COMMERCE, ITS AGENTS, INDEPENDENT CONTRACTORS, MEMBERS, AFFILIATES, PROVIDERS, ASSOCIATES, SPONSORS, CONTRIBUTORS, VOLUNTEERS AND EMPLOYEES, ARISING OUT OF OR RELATING TO THE UNDERSIGNED’S PARTICIPATION AS A MENTOR, INCLUDING TRAVELING TO AND FROM THE VARIOUS ACTIVITIES AND EVENTS, IN THE LEAD PROGRAM.
If any provision of this document is held to be invalid or unenforceable for whatever reason, it shall be construed to have the broadest interpretation that would make it valid and enforceable. Invalidity of one provision shall not affect the validity of any other provision of this document.
Signature* Date
Copy of Driver's License*

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Copy of Car Insurance*

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Should be Empty:

LEAD Returning Mentor Application

PHOTO/VIDEO RELEASE

RELEASE, AGREEMENT NOT TO SUE AND INDEMNITY AGREEMENT