Parent Registration

Semester
Fall Semester (10 Weeks) Spring Semester (12 Weeks) Fall and Spring (22 Weeks)

Youth Mentee Full Name

Mentee Birthdate

Mentee Email

Mentee Age

Name Of School

Grade

Parent / Guardian Full Name

Parent / Guardian Email

Mentee Street Address

Mentee City

Mentee State

Mentee Zip

Phone Number
Cell Home Work

QUESTIONNAIRE

1. Why do you/your child want to participate in a mentoring program?

2. Briefly describe your expectations of the Rise and Thrive Inc. mentoring program?

3. Is your child available to meet with a mentor for a minimum of one hour per week? If No Please explain any particular scheduling issues that you may have.

4. Describe your child’s school performance including grades, homework, extracurricular activities, school attendance, behaviors, etc.

5. Can you provide any additional background information that may be helpful for Rise and Thrive Inc. to complete a successful mentorship program with your selected mentee?

Please read this carefully and check the boxes to agree before signing:

  I give my informed consent and permission for my child to participate in the Rise and Thrive Inc. Mentoring Program and its related activities.
  I agree to have my child follow all of the mentoring program guidelines and understand that any violation of my child’s part may result in suspension and/or termination of the mentoring program without refund.
  I hereby acknowledge that my child may be transported by his/her mentor while participating in the mentorship program, and that such transportation is voluntary and at his/her own risk.
  I release Rise and Thrive Inc. Mentoring Program of all liability of injury, death, or damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined. I understand that I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of this application being processed: • Signed application • Contact and Media Release Form • Youth Mentee Guidelines/Instructions Form By signing below, I attest to the truthfulness of all information listed on this application and agree to all of the above terms and conditions.

Emergency Contact Info

Parent / Guardian 1 Full Name

Parent / Guardian 1 Phone

Parent / Guardian 2 Full Name

Parent / Guardian 2 Phone

Emergency Contact Info: (to whom child may be released if guardian is unavailable)

Contact 1

Full Name

Relationship

Phone
Cell Home Work

Contact 2

Full Name

Relationship

Phone
Cell Home Work

SPECIAL CONDITIONS, DISABILITIES, ALLERGIES, OR MEDICAL EMERGENCY INFORMATION

Doctor Full Name

Doctor Phone

Media Release

I, as the parent or guardian, hereby give Rise and Thrive and its employees, representatives, and authorized media organizations permission to publish, print,photograph, and record my child for use in photographs, or any other electronic,digital and printed media. This is with the understanding that Rise and Thrive and its representatives will utilize these photographs, and or media files for use in promotion of the organization; these files may be found on the organization website, social media, in-person presentations, and other presentations involving Rise and Thrive. I am also fully aware that I will not receive monetary compensation for my child’s participation. I further release and relieve Rise and Thrive, its CEOs and founders, 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. *

Policy Agreement

• Mentees should be dependable and punctual. If you will be late or absent, please notify a mentor as soon as possible.
• Mentees should fully participate in Rise and Thrive Inc. related activities and programming. We encourage mentees with cell phones to join the mentee-mentor GroupMe; it will be used as a quick communication tool.
• Mentees should treat mentors, peers, and guest speakers with respect and kindness. Rise and Thrive Inc. has a zero-tolerance policy against bullying of any sort (including cyber bullying).
• Mentees should limit cell phone usage during mentoring sessions. Mentees are encouraged to have their cell phones, but silenced or in their book bags during sessions.
• Mentees should not utilize drugs or alcohol. Drug and alcohol use of any kind are strictly prohibited prior to or during any mentor-mentee activity. Rise and Thrive Inc. has a zero-tolerance policy towards the use of drugs and alcohol.
• Mentees should not carry weapons of any kind when participating in any Rise and Thrive Inc. related programming. A dangerous weapon is a gun, knife, razor, karate stick, metal knuckles, or any other object that by the manner it is used or intended to be used is capable of inflicting bodily harm.
• Mentees should refrain from wearing clothing with undergarments showing, excessive amounts of skin, inappropriate references, and/or vulgar and obscene imagery.
• Mentees should have fun!

E-Signature
By typing your full name below you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.
* I have voluntarily provided the above contact information and authorize RISE AND THRIVE and its representatives to contact any of the above on my behalf in the event of an emergency.

Parent / Guardian Full Name

Parent / Guardian Email