Participant Registration Form

PLEASE NOTE: In a medical emergency, your child will be taken by ambulance (if necessary) to the closest hospital or trauma center. All medical fees will be the parent and/or guardians responsibility. Your signature below implies permission for the sponsors/youth leaders to sign all medical forms which are needed for emergency care. This will ensure that treatment of any injury can begin as soon as possible.

I give Growing Hearts, Healing Hands, Inc., and its designees permission to drive my child to and from events. I understand that permission forms for each off-campus event will be required and will supersede this permission.

I release Growing Hearts, Healing Hands, Inc. and their designees from any liability or cause in case of an accident that occurs during any Growing Hearts, Healing Hands, Inc. events/activities.

I give my child permission to participate in Growing Hearts, Healing Hands, Inc. groups and its auxiliary activities. I understand all of the permissions listed above. I understand that every effort will be made to contact parents before exercising the authority contained in this form.

It is the policy of the Growing Hearts, Healing Hands Inc. Youth Healing and Growth Program that unacceptable behavior will not be tolerated on the part of mentors or mentees while participating in the program. This policy is in addition to behavioral requirements stipulated in other policies or procedures within this manual. This policy in no way is intended to replace or take  precedence over  other policies or procedures including, but not limited to, the following:

• Overnight Visits and Out-of-Town Policy 
• Use of Alcohol, Drugs, Tobacco, and Firearms Policy
• Mandatory  Reporting of Child Abuse and Neglect Policy
• Confidentiality Policy

These behaviors are regarded as incompatible with the goals, values, the Growing Hearts, Healing Hands Inc. program  standards and therefore are considered unacceptable and prohibited while participants are engaged in mentoring activities :

• Unwelcome physical contact, such as inappropriate touching, patting, pinching, punching, and physical  assault
• Unwelcomed physical, verbal, visual, or behavioral mannerisms or conduct that denigrates, shows hostility, or aversion toward any individual.
• Demeaning or exploitative behavior of either a sexual or nonsexual nature, including threats of such behavior
• Display of demeaning, suggestive, or pornographic material
• Known sexual abuse or neglect of a child 
• Denigration, public or private, of any mentee parent/guardian or family member 
• Denigration, public or private, of political or religious institutions or their leaders
• Intentional violation of any local, state, or federal law
• Possession of illegal substances
• The use or being under the influence of any illegal substances or alcohol

Any unacceptable behavior, as specified but not limited to the above, will result in a warning and/or disciplinary action including suspension or termination from participation in the mentoring program.

I understand that if any child does not abide by the rules set by the program, she may be sent home and/or suspended from the program.

I                         agree that, in the consideration of the access to information provided at the Planning Committee Meetings of Growing Hearts, Healing Hands, INC. I will:

Keep and protect all information provided to me at the Growing Hearts, Healing Hands, INC. meetings related to business and/or marketing plans, discussions, research, graphic design, and marketing-related programs and processes under development in strict confidence. 

Disclose this information solely to individuals who have a signed non-disclosure agreement with, or who have expressed approval from the Growing Hearts, Healing Hands, INC. founder, through writing to receive such information.

Continue to keep the information disclosed as the  Growing Hearts, Healing Hands, INC. meetings confidential in the event that my position on the Planning Committee ends.

Mentoring Confidentiality Form

This form serves as a notice to all participants of Growing Hearts, Healing Hands, INC. that all information shared during the mentoring relationship is confidential. The only exception to this policy is:

• Concerns or reports that someone has been harmed
• Concerns or reports of the possibility of someone being harmed.
• Conduct that violates Growing Hearts, Healing Hands, INC. policies.

If the issue with confidentiality arises, the parties involved are asked to contact the Executive Director directly.

 
As a Mentoring program, Growing Hearts Healing Hands requests permission from the Parent/Guardians on which subjects the program can mentor to it’s mentees. Without an initial next to each subject we will respect the wishes of the Parent/Guardian and will not speak upon such subjects without written consent. 

Growing Hearts Healing Hands Mentoring Program is faith-based, the bible and devotionals will be used in some of the group meetings.  Growing Hearts, Healing Hands will not force religious belief on any of its mentees.

 

As the Parent/Guardian, we ask that there is an understanding that a mentee can come to the mentor with questions or concerns which are related to such subjects, and without written consent, we must refuse the advice to the mentee.

These subjects include but are not limited to:

• Academics       
• Crimes       
• Drugs/Alcohol     
• Family Issues                       
• Religion                      
• Sex     

Group Confidentiality Agreement 

As a participant of Growing Hearts, Healing Hands, Inc. part of your responsibility is to ensure that everyone feels comfortable. To ensure this, all participants must agree that any information shared remains within the group. As participants of Growing Hearts, Healing Hands, Inc. to receive the fullness of the program, every participant deserves the capacity to be transparent, while the other participants provide a trustworthy environment and respect for each others' feelings. This can only be ensured through the agreement of confidentiality. 

The consequences of breaking this confidentiality agreement may result in removal from the program.

Overnight Visits and Out-of-Town Travel Policy 

To be able to participate in any Growing Hearts Healing Hands Overnight or Out-of-Town stay, it must first be approved by the parent/guardian of the mentee.  A GPA of 2.5 is required for Overnight Visits and Out-of-Town travel. For any and all admissible out-of-town travel, the parent/guardian is required to sign a permission slip allowing their child to have permission to stay and travel to the determined destination. Also signing permission for medical treatment in the case of a medical emergency.

To qualify to participate in the Overnight Visits and Out-of-Town Travel, mentees must fulfill

• 80% of all group meetings
• Complete  90% of all the assignments
• Show some improvements in the Home and School 
• Participate in ALL  volunteer  events
• Come to the meeting dressed in the clothing requirements 

Every Overnight Visit and Out-of-Town travel will give parents and mentees an itinerary of the  following 

• The destination(s)
• Phone numbers of their cell phone, places being visited, and lodging.
• Times and dates of departures and arrival at each location being visited 
• Expected time and return

If at any time a mentee displays any unacceptable behavior they will be suspended from overnight visits and out-of-town travel for a year from the date it occurred. Mentees will still be required to fulfill all the requirements to qualify to participate in overnight and out-of-town travel for the whole year of suspension. 

Mandatory Reporting of Child Abuse and Neglect Policy 

It is the policy of the Growing Hearts, Healing Hands Inc. Youth Healing and Growth Program that staff, mentors, and other representatives of the program must report any suspected child abuse and/or neglect of program participants immediately. All such suspected reports must be made to the appropriate state and/or child abuse and neglect procedure.  

All mentors of the Growing Hearts, Healing Hands Inc. are required to undergo training as to what constitutes child abuse and neglect, what the state statutes are, and how to properly report such cases.

Any mentors accused of child abuse or neglect will be investigated by the agency. Contact with the program mentees will be restricted or constrained and/or the person in question suspended from employment or program participation per the decision of the executive director and board of directors until such investigation is concluded.

   Media Consent and Release Form 

Throughout the year, participants may be highlighted in efforts to promote Growing Hearts, Healing Hands, Inc. activities and achievements. For example, students may be featured in materials to train employees and/or increase public awareness of our community through newspapers, radio, TV, the web, DVDs, displays, brochures, and other types of media. 

I, as the parent or guardian of                                              , hereby give Growing Hearts, Healing Hands, Inc. and its employees, representatives, and authorized media organizations permission to print, photograph, and record my child for use in audio, video, film, or any other electronic, digital and printed media for the aforementioned purposes.

a. This is with the understanding that neither Growing Hearts, Healing Hands, Inc. nor its representatives will reproduce said photograph, interview, or likeness for any commercial value or receive monetary gain for use of any reproduction/broadcast of said photograph or likeness. I am also fully aware that I will not receive monetary compensation for my child’s participation. 

b. I further release and relieve Growing Hearts, Healing Hands, Inc. its Board of Trustees, employees, and other representatives from any liabilities, known or unknown, arising out of the use of this material. 

I certify that I have read the Media Consent and Release Liability statement and fully understand its terms and conditions. Please understand that failure to return this release form within ten (10) business days from the date of the distribution will constitute approval of the above requests.