Mentorship Permission Form

Mentorship Information Update Form

Please use this form if you need to update any information previously submitted on your child's permission form. The updated details will help us respond quickly and effectively in urgent or emergency situations. This form should be completed any time there are changes to your child's address, emergency contacts, medical information, or health insurance coverage.

Student Information

Student's Name*

First NameLast Name

Date of Birth*

Date

Parent/Guardian Info

Parent/Guardian Name*

First NameLast Name

Relationship*

Primary Phone Number*

Secondary Phone Number

E-mail*

I would like to update my child's:*

AddressEmergency Contact InfoMedical InfoHealth Insurance Information

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information

Please do not list yourself as an emergency contact. Emergency contacts may be used if we are unable to reach you.

Primary Emergency Contact*

First NameLast Name

Relationship*

Phone Number*

Secondary Emergency Contact*

First NameLast Name

Relationship*

Phone Number*

Medical Information

Does your child have any allergies?*

YesNo

Please list his/her allergies:*

Does your child have any medical conditions?*

YesNo

Please list his/her medical conditions:*

Is your child currently taking medication?*

YesNo

Please list his/her medications:*

Does your child have a primary care physician?*

YesNo

Name of Primary Care Physician*

Name of Clinic*

Clinic Phone Number*

Health Insurance Information

Is your child covered with health insurance?*

YesNo, I'll cover medical expenses with cash.

Insurance Carrier*

Name of Policy Holder*

Subscriber ID/Group Number*

Insurance Card Number/Date*

Terms of Agreement

PART 1: AGREEMENT TO PARTICIPATE AND HOLD HARMLESS

I am the parent or guardian of the child listed above and I authorize my child, for his/her own benefit, to participate in Urban City Impact's mentorship program.

In agreement to participate in mentorship program, my child and I recognize that certain risks and dangers exist. These risks include but are not limited to the loss of personal property and personal injury or fatality, which may result from participating in sports, using workout equipment, exercising, cooking, chopping firewood, tripping, falling from heights, drowning, allergic reactions to food, plants, animals or insects, animal bites, exposure to extreme temperature or inclimate weather, and vehicle accidents.

My child and I agree to obey the rules and safety procedures for the mentorship program. We also agree to obey the instructions of the staff directing the events and understand that Urban City Impact, its staff, and other participants shall assume no responsibility or liability to me for accidents, illness, personal injury, loss or damage to personal property caused by risks inherent in the activities in which my child and I are willing participants. I acknowledge and assume all risks in connection with this mentorship program, and I hold Urban City Impact and its agents harmless from any and all liability, action, claims, and damage of every kind.

PART 2: AGREEMENT TO FOLLOW RULES

I hereby acknowledge that my child's participation in mentorship activities is contingent upon their good health and I pledge to prevent their participation while unwell. I agree to ensure my child's timely readiness, 15 minutes prior to scheduled pick-up times. I understand that the possession and/or use of prohibited substances is strictly forbidden. I acknowledge that vapes and other illicit substances are subject to confiscation from my child and any resulting altercations will lead to suspension or expulsion from the mentorship program. I understand that Urban City Impact operates under the same rules and expectations as Hampton City Schools. I acknowledge that severe behavioral infractions may result in suspension and expulsion from Urban City Impact's mentorship program. My child and I agree to adhere to all rules, both written and verbal.

PART 3: PHOTO RELEASE 

Furthermore, I hereby grant permission to Urban City Impact, its staff and volunteers to use any photographs, motion pictures, recordings, and any other record of my child's participation in Urban City Impact's activities and events for any legitimate purpose.

PART 4: AUTHORIZATION FOR EMERGENCY MEDICAL CARE

I am aware of my child’s general condition and affirm that he/she is fit to participate in any activities required for participation in Urban City Impact's outings. I willfully disclose any relevant medical information on this form and to Urban City Impact's staff. My child will engage in all prescribed activities except for those noted by me and/or by my examining physician. I agree to provide medical documentation and I permit the staff to contact my child’s healthcare providers to inquire of medical needs and I authorize the staff to copy and release my child’s medical information to those who need to review it for purposes related to Urban City Impact's events and activities. If required by the Health Insurance and Accountability Act (“HIPAA”) to execute medical releases, I will execute all such releases pursuant to HIPAA, prior to my child engaging in any activities or trips.

In the event of illness, accident or emergency, I authorize and request that any medical and surgical services that may be necessary be taken, and further agree to accept financial responsibility to seek approval from a medical provider in order for my child to participate in Urban City Impact's mentorship program and its activities should his/her physical, mental or medical status change.

By my signature, I acknowledge that I have read and understand this form in its entirety. I also acknowledge that I agree to the terms listed above. Furthermore, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge*