BOOST Program Application

Mentorship Academy BOOST Application
Mentorship Academy Advance Training Institute BOOST Program Application

The Building Opportunities in Out-of-School Time (BOOST) grants program offers grants to community-based organizations that operate comprehensive out-of-school time (OST) programming year-round, during the summer months, or after school during the academic year. The goal is to provide evidence-based afterschool and summer enrichment programming that supports students in learning essential skills and concepts while addressing non-academic barriers to learning through a whole child approach.

Our BOOST Program is recognized as a superior system that prepares students for:
- Academic acceleration and learning support;
- Childcare and youth development programming;
- Supports for youth well-being;
- Enrichment programming;
- Access to new and emerging technologies.
Afterschool and summer learning programs play a vital role in supporting Georgia’s children and families and in advancing academic achievement and youth development.
1. Student's Name (First and Last)*
2. Student's Personal Email (Non-School Email)*
example@example.com
Student T-Shirt Size (Adult Sizes)*

SmallMediumLargeX-Large2X-LargeOther
3. Confirm Student's Personal Email*
example@example.com
Student's Date Of Birth*

MonthDayYear
Date
5. Student's Cell Phone #*
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
7. Age*
Sex*

FemaleMaleNon Binary
Are you a U. S. Citizen?*

YesNo
Are you a Permanent Resident? (Non-US Citizen)*

YesNo
Alien Registration Number (type N/A if not applicable)*
Ethnic Origin*

American Indian/Alaskan NativeAsian/Pacific IslanderBlack(Non-Hispanic)HispanicWhite (Non-Hispanic)
Current Grade Level*

3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeFreshman (9th)Sophomore (10th)Junior (11th)Senior (12th)
Are you currently in Middle or High School?*

Elementary SchoolMiddle SchoolHigh School
Current School Name*
Will you need transportation from school to the EpiCenter? (Transportation MAY be provided based on need and location of school)

YesNo
Who do you live with*

Both ParentsParent & Step-parentMotherFatherGrandparentsFoster ParentLegal GuardianOther
Please check all your program interests.

Career choices/planningCollege admissions/requirementsDance / MovementCommunity ServicePerforming Arts / TheaterStudy SkillsCollege/University ChoicesTutoringFilm & Digital MediaPE / Health & FitnessHomework HelpE-Gaming / EsportsPodcasting / Media ProductionI would like to explore careers in the STEM (Science, Technology, Engineering and Math) fieldsI have an interest in pursuing a career in the STEM (Science, Technology, Engineering and Math) fieldI would like to learn more about financial economic literacy, financial aid, and scholarshipsOther
Parent/Legal Guardian 1- First/Last name*
Parent/Legal Guardian Cell Phone #*
Parent/Legal Guardian Email Address*
Highest Education Attained by Parent/Guardian 1*

Some High SchoolHigh School DiplomaGEDSome CollegeAssociate's DegreeBachelor's DegreeGraduate/Professional Degree
Parent/Legal Guardian 2- First/Last name
Parent/Legal Guardian Cell Phone #
Parent/Legal Guardian Email
Highest Education Attained by Parent/Guardian 2

Some High SchoolHigh School DiplomaGEDSome CollegeAssociate's DegreeBachelor's DegreeGraduate/Professional Degree
Do you receive Free or Reduced Lunch?

Free LunchReduced LunchNeither
Number of Members in Household*
Total taxable income (adjusted gross income-deductions and exemptions): This is featured on line 10 of the 1040 form (2020 or 2021)*
Total annual gross income for all parent(s)/guardian(s) living with the student*
Indicate untaxed income or benefits received:*

Social SecuritySSIVeteran's BenefitsPublic AssistanceTANFVocational RehabiliationOther
Parent's Name*

First NameLast Name
I certify that all financial information provided in this application is accurate. I understand that falsifying information will result in immediate rejection of this application.*

Clear
Parent Signature
Liability Waiver Form

LIABILITY WAIVER, ASSUMPTION OF THE RISK, AND INDEMNIFICATION AGREEMENT FOR THE MENTORSHIP ACADEMY BOOST PROGRAM

In consideration for being allowed by Mentorship Academy, to participate in the BOOST Program the undersigned custodial parent/guardian hereby agrees as follows:

I do hereby affirm and acknowledge that my child is participating in the Program for his/her own personal benefit and have been fully informed of the inherent hazards and risk to them associated with this activity including property damage, falls, contact with other participants, motor vehicle accidents, sprains, and other personal injuries. I accept and assume responsibility for all risks, known and unknown, involved to my child and their property in the aforementioned activity, and I voluntarily authorize my child’s participation in reliance upon my own judgment and knowledge of my child’s experience and capabilities.

I understand that the determination of my child’s ability to participate in the Program should be made by my child’s physician if necessary. I understand that I need the approval of a physician if I am uncertain as to his/her physical fitness for the rigors of this Program. I understand that I may be required to seek approval from a physician if there is a health safety question relative to my child’s condition before being allowed to participate in the Program. In addition, I give permission to any doctor, hospital, or other medical facilities to release confidential to the treating physician(s) for my child any information they may have concerning his/her medical condition and their professional contact with him/her for treatment purposes. I hereby grant my permission for such diagnostic, therapeutic, and operative procedures as deemed necessary for a child. A photocopy of this permission is to be considered valid as the original. I further understand that treatment for any medical problems my child may suffer is my responsibility and will be paid by me and/or covered by my insurance.

I shall indemnify and hold harmless Mentorship Academy, and its trustees, officers, employees and agents from any liability, losses, costs, damages, claims or causes of action of any kind or nature whatsoever, and expenses, including attorney’s fees, arising from, or proximately caused by my child’s participation in this program, including any travel. I further agree to accept and assume for myself, my assigns, executors, and heirs any and all such risks and losses that may occur.

I have read the Program’s rules and regulations and hereby accept the regulations of the Program described therein. I understand that the Program has the authority to establish and enforce other regulations in addition to these.

I understand that this is a legal document that is binding on me, my heirs, and assigns and on those who may claim by or through me. I am eighteen years of age or older, have the full capacity to enter into this agreement and do so voluntarily.
I have read and understand the Liability Waiver Form. I understand that the information will be kept in confidence and will not be revealed to anyone except Mentorship Academy BOOST personnel in accordance with the Family Educational Rights and Privacy Act.*

I have read and understand the Liability Waiver Form
Student's Name*

First NameLast Name
Parent/Guardian's Name*

First NameLast Name
Parent or Guardian's Signature *

Clear
Date*

MonthDayYear
Date
Signature and Authorization

I agree that all the information provided is true to the best of my knowledge. I also understand that any false information I have provided may result in the denial of my application and/or my immediate dismissal from the program. I understand that if I enroll in any Mentorship Academy BOOST Program, I must participate in activities designed to achieve my academic goals and promote my holistic development.
I certify that all information provided in this application is accurate. I understand that falsifying information will result in immediate rejection of this application.*

I Certify
Authorization to Release Information:

I authorize Mentorship Academy BOOST Program personnel to obtain copies of my child's transcripts, grade reports and test scores, or any other information necessary to determine eligibility for services. I permit the BOOST Program Staff to release confidential information to scholarships, post-baccalaureate, or external programs for educational planning purposes.
I authorize Mentorship Academy BOOST Program personnel to obtain copies of my child's transcripts, grade reports and test scores, or any other information necessary to determine eligibility for services. I permit the BOOST Program Staff to release confidential information to scholarships, post-baccalaureate, or external programs for educational planning purposes.*

I authorize
Privacy Act:

I understand that the information will be kept in confidence and will not be revealed to anyone except Mentorship Academy BOOST personnel in accordance with the Family Educational Rights and Privacy Act.
I have read and understand the Privacy Act. I understand that the information will be kept in confidence and will not be revealed to anyone except Mentorship Academy BOOST personnel in accordance with the Family Educational Rights and Privacy Act.*

I have read and understand the Privacy Act.
Student's Name*

First NameLast Name
Student Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian's Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Health Form

AUTHORIZATIONS:

(Parent or legal guardian MUST sign if under 18 years of age)

I hereby accept financial responsibility for the expense of health care services and I authorize the medical providers of Mentorship Academy Student Health Services and their agents or consultants, including emergency medical technicians, area hospitals or other treatment facilities, to perform diagnostic and treatment procedures, on the below named student, which in their judgment may become necessary while he/she attends Mentorship Academy events.

I have no expectation for Mentorship Academy to pay medical expenses for the student should he/she need treatment outside of Student Health Services.

I agree to absolve and hold harmless Mentorship Academy in making medical decisions for the student.

I understand that every effort will be made to notify the parent or legal guardian once permission is obtained from the student in the event of a major illness or injury.

I understand that the parent or guardian may not necessarily receive notification prior to treatment.
Medical release for: Childs Full Name *
Parent Signature*

Clear
Date*

MonthDayYear
Date
In case of emergency, notify*
Emergency Contact Cell Phone #*
I do hereby grant permission to the Director of Mentorship Academy, or the Director’s authorized representative and staff, to furnish first aid as my child (named above) may require, as well as to seek medical attention through the nearest medical facilities such as those provided on campus and those medical facilities available when students are on field trips and other authorized activities.

This permission is conditioned upon the understanding that, in the event of serious illness or the need of hospitalization and/or major surgery, the Director from providing such emergency treatment as any be necessary for the best interest of the life of my child.

A photocopy of this permission is to be considered valid as the original.

I further understand that treatment for any medical problems my child may suffer is my responsibility and will be paid by me and/or covered by my insurance.
Student's Name*

First NameLast Name
Student's Name

First NameLast Name
Parent's Name*

First NameLast Name
Parent Signature*

Clear
Date*

MonthDayYear
Date
I certify that all information provided in this application is accurate. I understand that falsifying information will result in immediate rejection of this application.
Upload Passport Style Photo*

Cancelof
Student's Name*

First NameLast Name
Student Signature that you certify*

Clear
Parent's Name*

First NameLast Name
Parent Signature that you certify*

Clear
Should be Empty:

Mentorship Academy BOOST Application

Signature and Authorization

Authorization to Release Information:

Privacy Act:

I certify that all information provided in this application is accurate. I understand that falsifying information will result in immediate rejection of this application.