Mentoring Club Application

Mentoring Club Application

Royal Family KIDS Mentoring is a 1X/ Month opportunity for children ages 6-12 years in the foster care system to spend time with a trained and background checked mentor. These times will be in a group setting. Date and time TBA. Please complete this form to have your child considered for Royal Family KIDS Mentoring.
Child's Full Name

First NameLast Name
Child's Preferred Name
Date of Birth

MonthDayYear
Date
Sex
School
Grade
Caregiver's Name
Caregiver's Relationship
Caregiver Email Address
example@example.com
Caregiver Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Medical Release Information
This Medical Release Form is effective on the date of submission and will remain in full force and effect as long as my child participates with Royal Family KIDS Mentoring Club in any manner; it applies to all Mentoring Club activities, including both individual meetings with a Club mentor and group meetings, functions, and events.

I hereby give permission for my child to attend and participate in the Activities. I specifically authorize Royal Family KIDS Mentoring Club to provide for, and arrange in my place, necessary medical care.

I authorize the Royal Family KIDS Mentoring Director or any designated adult, in whose care my child has been entrusted, to arrange for and consent to any x-ray examination, anesthetic, and/or medical, surgical and dental procedure and treatment, and hospital care, to be rendered to my child under the general or special supervision, and on the advice of any physician or dentist duly licensed by an appropriate regulatory agency, or the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of such physician, dentist or hospital. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical, dental and/or hospital services rendered to my child pursuant to this authorization. Should it be necessary for my child to be transported home or to medical facilities due to medical reasons or otherwise, the undersigned shall assume all transportation costs.
This Medical Release Form will be used only as necessary in the circumstances. Every reasonable effort will be made to first notify a caregiver listed below prior to the use of the Medical Release Form.
Emergency Contact (other than Caregiver above)
Emergency Contact Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Mark any of the following that your child is allergic to:

Other
If other, please describe
My child has a history of the following:
If "other" please describe
My child is taking the following medications (prescriptions or otherwise):
My child is receiving medication or has a condition that may affect behavior or increase risks. Please describe.
Current caseworker name
Caseworker phone #
Please enter a valid phone number.Format: (000) 000-0000.
Family Physician
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Date of most recent exam

MonthDayYear
Date
Transportation/ Activities Permission and Release Information
As the undersigned legal parent or caregiver, I request that my child be allowed to participate in the Royal Family KIDS Mentoring program.

This Transportation/ Activities Permission and Release Form is effective on the date of submission and will remain in full force and effect as long as my child participates with Royal Family KIDs programs in any manner; it applies to all Mentoring Club activites, including Royal Family KIDS Mentoring Club meetings and group meetings, functions, and events.

I hereby give permission for my child to ride in any vehicle designated by the adult(s) in whose care my child has been entrusted while participating in the Activities.

In consideration for permitting my child to attend and/or participate in the Activities, I do hereby release, and on behalf of my child release, Royal Family KIDS Mentoring program, the local Club's mentors, Club leaders, volunteer assistants, the host church, and any designated driver of a van, bus, car, or other vehicle used in connection with any of the Activities(Released Parties) from any and all claims for injuries, losses, damages, costs and expenses that I , and/or my child, might have against the Released Parties, arising out of, or in any way relating to, my child and the Activities, and I agree to hold the Released Parties harmless from any loss arising from such claims.
I certify that I have read, understand, and agree to the provisions of this Transportation/ Acitvities Permission and Release Form, including the Medical Release Form.
Name
Date

MonthDayYear
Date
Should be Empty: