NCBW Harrisburg - S.T.A.R.S. Mentoring Program Registration Form

NCBW Harrisburg Chapter - S.T.A.R.S. Mentoring Program Mentee Registration Form
Please fill the form in its entirety.

A separate form must be completed for all participating young ladies.

Direct all questions to: ncbwharrisburg@yahoo.com

Mentee Information
Youth Participant Name:*

First NameLast Name
Age:*
Date of Birth*

MonthDayYear
School Attending*
Grade:*
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.*
T-Shirt size:
Does youth have internet access for virtual mentee check-ins?

Primary Parent/Guardian Contact Information
Parent/Guardian Name:*

First NameLast Name
Relationship:
Mobile Phone:*
Home Phone:*
E-mail:*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information.(this person has permission to pick up your child or be called in case of emergency)
Name (contact #1):*

First NameLast Name
Relationship:
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Name (Contact #2):

First NameLast Name
Relationship:
Phone Number:
Please enter a valid phone number.
Email:
example@example.com

Liability Information
PARENT/GUARDIAN CONSENT

I, the parent or legal guardian for mentee name stated above hereby give my permission for my child to participate in the NCBW Inc. S.T.A.R.S Mentoring Program.

I fully understand that the program involves mentors/organization members and subject matter presenters, who shall be selected from the community and will be screened. The mentor is not allowed to take or meet my child beyond the planned in-person sessions unless otherwise communicated and agreed upon by the parent/guardian in advance.

I understand that my child will participate in an sessions from January 2025- June 2025.

I understand that during the course of the mentoring program there may be special group events (incorporating all mentors and youth) and family events planned. I understand that the staff of the mentoring program will provide ongoing monitoring of the S.T.A.R.S mentoring activities.

I permit the S.T.A.R.S Mentoring Program staff and NCBW Inc. Harrisburg Chapter to utilize photographs of my child taken during his/her involvement in the mentoring program and waive all rights of compensation.

I understand that as a participant my/our child may be quoted, photographed or videotaped during normal mentor activities or events and that these quotes/photos/videos may be used in promotional materials. I, the undersigned, do hereby release and discharge S.T.A.R.S Mentoring Program from any and all claims, costs, demands, actions or causes of action, past, present, or future arising out of any damage or injury my child may incur while participating in Mentoring activities. I agree to indemnify S.T.A.R.S Mentoring Program for any and all claims, demands, damages, injuries, costs, suits or causes of action, past, present or future, arising out of or caused by my child while
participating in S.T.A.R.S Mentoring Program activities.
CONSENT FOR MEDICAL TREATMENT | As the parent or legal guardian of the above-named participant, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent.

Signature
By signing and submitting this registration form, you acknowledge that you understand and agree to all terms.
Signature*

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NCBW Harrisburg Chapter - S.T.A.R.S. Mentoring Program Mentee Registration Form