UL Men of Valor Registration Form

GTHSGTC Men of Valor Mentoring

Registration
Dear Parent/Guardian:

On behalf of Alpha Phi Alpha Fraternity, Inc., Upsilon Lambda Chapter, and West Jacksonville Church of God in Christ, we would like to extend our sincere gratitude for your interest in the "Men of Valor" program. We are thrilled to partner with you in shaping the lives of young men through this transformative initiative.

The "Men of Valor" Project leverages Alpha Phi Alpha's national program curriculum (Go to High School Go to Collge (GTHSGTC)) which is designed to empower young men to embrace a life of excellence, equipping them with the principles and values necessary to make impactful decisions. Through our focus on education, bravery, discipline, and spiritual growth, we are committed to developing leaders who will be known as Young Men of Valor.

To participate in this program, please complete all required fields and signatures on the attached application. For your application to be considered, all required information and signatures must be completed in full.

We look forward to working together to inspire greatness in the next generation.

If there are any questions, please do not hesitate to email them to: ULGrants@gmail.com

Sincerely,

Dr. Gregory Bostic, President

Charlie J. Gillette, Jr., Esquire; Director - Director of Educational Activities

Roger Williams, - Men of Valor Mentoring Program Coordinator

ABOUT THE PROGRAM

The GTHSGTC and "Men of Valor" Project is Administered by the Upsilon Lambda Chapter of Alpha Phi Alpha Fraternity, Inc. and hosted by West Jacksonville Church of God in Christ, this program offers monthly growth and development sessions that include food, games, and engaging activities centered around three core principles: Leadership, Academics, and Social Skills. Group sessions are held once a month on the 4th Saturday.

Program Details:

Who: Male students, ages 8 - 18
When: 4th Saturday of each month at 10AM - 12PM
Where: West Jacksonville Church of God in Christ (3838 Firestone Rd, Jacksonville, FL 32210)

Lunch:

Lunch is included FREE of charge and served during program hours.

Transporation:

Parent/Gardian is responsible for ensuring their son arrives to programming on time and is picked up at dismissal.

Open Program Format:

To gain the most from the M.O.V. program students are encouraged to attend every session. However the open program format allows students to benefit from each session individually. Students can register and start any time throughout the year.

Costs:

The program is FREE. There may be small costs for field trips or add on activities on a case-by-case basis.

Communication:

Program communication is via the GroupMe App. The GroupMe App can be downloaded for free on iPhones and Android Phones. Parents/Gardian and participants will be added to the M.O.V. GroupMe after their registration information is received and verified.

Registration:

Students must be registered to participate. Fill in required information on the following pages to register your student.
I have read and understand the M.O.V. program overview and requirements.*

YES

Student Returning from Previous Year?*

YesNo
Student Name*

First NameLast Name
Age*
Birth Date*

MonthDayYear
Grade for Current School Year*
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Cell Phone Number (if applicable)

Area CodePhone Number
Student Emai (if applicable)
example@example.com
School Name (Please type FULL name of school without abbreviation)*
School City*
School County*
Student Identification Number (School ID#)(8 Digits, No letters)*
T-shirt / Polo Size *
(Best efforts will be made to provide the size selected. Some vendors do not offer certain sizes).
Extra-Curricular Activities:
Talents: (What do you do best?)
What do you hope to gain from participating in the M.O.V. Program?
What subject(s) would you like to learn about or are you interested in?
Parent/Guardian #1 Name*

First NameLast Name
Parent/Guardian #1 Cell Phone Number*

Area CodePhone Number
Parent/Guardian #1 Email*
example@example.com
Parent/Guardian #2 Name

First NameLast Name
Parent/Guardian #2 Cell Phone Number

Area CodePhone Number
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name (If parent/guardian is not available):*

First NameLast Name
Emergency Contact Cell Phone Number*

Area CodePhone Number
Emergency Contact Email
example@example.com
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Relationship to Child*
SPECIAL NEEDS OR MEDICAL CONDITIONS
Please indicate any special needs or disabilities, allergies, food allergies, medications, etc., that we should know about. Include any relative information with this form. We will contact you for further information.
DIETARY RESTRICTIONS
Please indicate any special dietary restrictions such as vegetarian or food allergies.

PARENTAL CONSENT FOR YOUTH PARTICIPATION

I hereby grant consent for my child, {studentName}

permission to participate in Upsilon Lambda Chapter of Alpha Phi Alpha Fraternity Incorporated's youth activities, including but not limited to: Men of Valor, Go-To-High School Go-To-College, Project Alpha, Big Brothers, Big Sisters and designated community service activities for programming period September 2024 - August 2025.

I understand the following:
- The program consists of monthly group sessions with students and quarterly special activity workshops which may include youth from school or community programs.
- Parent RSVP and student sign in is required to attend sessions. This helps us manage meal planning and other logistical needs, ensuring we can provide the best experience for all participants.
- Project Alpha is a special curriculum for High School participants only, that focuses on male sexuality, relationships and responsibility.
- I understand my child’s affiliation and involvement with this program in no way is a prelude to membership or a guarantee of future membership in Alpha Phi Alpha Fraternity, Inc.
MEDIA CONSENT

I hereby give consent and permission to the Upsilon Lambda Chapter of Alpha Phi Alpha Fraternity Incorporated and others working for it or on its behalf, and their respective licensees, successors, and assigns, the unlimited right and permission to use, distribute, publish, exhibit, digitize, broadcast, display, reproduce, my name, picture, likeness, and voice, in all forms of media for the purposes of advertising, promoting, and publicizing the Upsilon Lambda Chapters programs and any lawful purpose whatsoever.

I shall have no right of approval, no claim to compensation, and no claim (including, without limitation, claims should be based upon invasion of privacy, defamation, or right of publicity) arising out of any use, alteration, blurring, distortion, faulty reproduction, illusionary effect or use in any composite form of my name, picture, likeness, and voice.

I have the full right and authority to grant the rights granted hereunder, and I agree that this Consent and Release does not in any way conflict with any existing commitment on my part. I have not heretofore authorized (which authority is still in effect), nor will I authorize or permit the use of my name, picture, likeness, voice, and biographical information in connection with the advertising or promotion of any product or service competitive to or incapable with those of the Men of Valor Program.

HOLD HARMLESS AGREEMENT

I understand that participation in the Men of Valor involves a certain degree of risk. I have carefully considered the risk involved and have given consent for myself or my child to participate in the activity. I understand that participation in the activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release Alpha Phi Alpha Fraternity, Inc., the Upsilon Lambda chapter, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation.

In case of an emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child.
Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program.
Signature*

Clear
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GTHSGTC Men of Valor Mentoring