Miss Mosaic Mentoring Program Mentee Application Form

Email questions to: ncbwchicagomentoring@gmail.com

As a Miss Mosaic mentee, you will become an integral part of an exciting program that is designed to serve, support, and develop YOU! All participants are required to attend monthly activities from September-June (dates will be provided well in advance To ensure that you gain the most from The Miss Mosaic Mentoring Program, you will need to make every effort to attend and fully participate in these activities. There will also be personal growth opportunities (i.e., goal-setting, personal reflections, mentoring, "team tasks", etc that must be completed between monthly meetings. Please answer the following:

 

 

Will you make every effort to meet/complete all Miss Mosaic tasks/assignments? 

Will you try your best to attend the monthly group activity?

Will you respond to messages from Mentors (email or text) in a timely manner?

Miss Mosaic Program Eligibility Requirements: Girls must be in grades 7th - -10th to enter The Miss Mosaic Mentoring Program. Girls must attend school and reside in the Chicagoland Area. Girls must demonstrate a desire to participate in the program and be willing to abide by all Miss Mosaic Mentoring Program policies and procedures. Parents/Guardians must consent to their child's participation in the program by completing all application materials and subsequent forms requiring consent and permission and attending orientation. Girls/parents/Guardians must be willing to participate for a minimum of two (2) years (minimum number of years required to qualify for a college scholarship) Girls must maintain 75% attendance (6 out of 8 meetings) and attend the mandatory September and May meetings/activities to remain in the program. Girls/parents/Guardians must be willing to communicate any concerns with the Miss Mosaic Mentoring Committee/Co-Chairpersons regarding meetings and

National Coalition of 100 Black Women Chicago Metropolitan Chapter

Parent/Guardian Consent and Waiver of Liability

(parent or legal guardian), for and in consideration of the participation of my child/youth (name of youth) in the Miss Mosaic Mentoring Program, offered by the Chicago Metropolitan Chapter of the National Coalition of 100 Black Women, Inc., and in which I freely and voluntarily permit my child to participate, do hereby agree and understand not to hold the Chicago Metropolitan Chapter of the National Coalition of 100 Black Women, Inc., their officers, administrators, employees, representatives and/or agents, and their heirs, successors, and assigns, liable in any way, what so ever, for any injury, or damage, or loss of property sustained by my child or persons other than my child arising out of, or in connection with, or due to negligence, fault, or otherwise during any part of my child's participation in the aforementioned program.

For the same consideration and without conflict in the foregoing, voluntarily and knowingly, I hereby release and discharge the Chicago Metropolitan Chapter of the National Coalition of 100 Black Women, Inc., officers, administrators, employees, representatives and/or agents, and their heirs, successors, and assigns, both in their official and individual capacities jointly and severally, from any actions, causes of action, claims, demands, damages, costs, and expenses on account or in any way growing out of any and all loss of personal property, or injury, as the result of any accident, delay, or irregularity which may be caused either in whole or in part by any defect in any vehicle, airplane, vessel, or negligent operation thereof and through any act, error, or omission, or default of any company or person, or by reason of the conditions or use of any real or personal property while I am in route to, or from or participating in the program or occasioned by it.

I further promise to bind myself, and all my heirs, administrators, and executors, to indemnify and forever hold harmless the Chicago Metropolitan Chapter of the National Coalition of 100 Black Women, Inc., their officers, administrators, employees, representatives and/or agents against loss, damage, or expense from any and all claims, demands, actions, or causes of action that may occur while in route to, or from, or participating in the program or any activity relating or occasioned by it.

Additionally, I will provide my child's report card (as requested) to allow facilitators to monitor academic progress. I have read this release, understand the contents, and execute it voluntarily and with full knowledge of its impact.