ENROLLMENT FORM
Participant Information:
Name:
Age:
Date of Birth:
Address:
Phone:
Format: (000) 000-0000.
Email:
Emergency Contact:
Name:
Relationship:
Phone:
Format: (000) 000-0000.
(This program requires participation in mental health support.)
Are you currently in therapy? (Yes / No)
Yes
No
Are you willing to participate in therapy during the program? (Required: Yes)
*
Yes
No
HEALTH INFO
Any medical conditions?
Any allergies?
Any medications?
Back
Next
INSURANCE INFORMATION (Required)
Insurance Provider (Dropdown or Short Answer)
(Examples: Medicaid, Priority Partners, Amerigroup, CareFirst, etc.)
Member ID Number
Group Number (if applicable)
Policy Holder Name
Policy Holder Date of Birth
-
Month
-
Day
Year
Date
Relationship to Participant
(Self / Parent / Guardian)
*
"I understand that my insurance information may be used to support mental health services provided through program partnerships."
Back
Next
CONSENT & AGREEMENTS
Inside Out Program Participation Agreement
*
"I understand that participation requires both mentorship and mental health engagement."
"I understand that participation requires some daily physical activity."
"I understand that judgement of others is not excepted yet encouragement and motivation.
I agree that:
I will attend scheduled sessions
I will respect program staff and participants
I understand that failure to participate in required mental health services may result in removal from the program
Participant Signature:
Parent Signature:
Date:
-
Month
-
Day
Year
Date
Back
Next
PHOTO & MEDIA CONSENT FORM
ABE Nation Outreach Ministries Inc.
I,
grant permission to ABE Nation Outreach Ministries Inc. to use photographs, video recordings, and/or digital images of myself (or my child) for:
Purposes for media use:
Promotional materials
Social media
Website content
Grant reporting and presentations
I understand that:
Images may be used without compensation
My name may or may not be used
These materials may be used in future campaigns
I release ABE Nation Outreach Ministries Inc. from any liability related to the use of these images.
YES, I give consent
NO, I do not give consent
Participant Name:
Parent/Guardian Name (if under 18):
Signature:
Date:
-
Month
-
Day
Year
Date
Back
Next
Individual Insight
Why do you want to join this program? (Short answer)
What are some goals you have for yourself?
Have you ever worked with a mentor before? (Yes/No)
PARENT ACCOUNTABILITY AGREEMENT FORM
I understand that this program includes:
Mentorship activities
Physical activity
Mental health participation
I agree to:
Ensure my child attends regularly
Support their participation in therapy
Communicate with program staff
Parent Name:
Signature:
Date:
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: