One-On-One Mentorship Registration

Name: One-On-One Mentorship Registration
SKU: 1363
Price: 125.00 USD
Availability: InStock

$125.00

$125 per session per 1 hour
Note: If you would like to register for more than 1 hour, please increase the quantity.

One-On-One Mentorship Registration

Please complete this short form to discuss private mentorship for our mentee of interest. Note: $125.00 / session (Each session is 1 hour)

Youth Mentee Full Name*

Mentee Birthday*

Mentee Email*

Mentee Age*

Name of School*

Grade Level*

Mentee Full Address*

Parent/Guardian Full Name*

Phone Number Type*

Phone Number*

Questionnaire

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

Emergency Contact Info

Parent/Guardian 1 Full Name*

Parent/Guardian 1 Phone Number*

Parent/Guardian 2 Full Name

Parent/Guardian 2 Phone Number

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

Contact 1 Full Name

Contact 1 Relationship

Contact 1 Phone Number

Contact 2 Full Name

Contact 2 Relationship

Contact 2 Phone Number

Please list all special conditions disabilities allergies or medical emergency information:*

Doctor Full Name*

Doctor Phone Number*

Consent and Authorization

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.*

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.*

I Agree

I Do Not Agree

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-Consent*

I Agree

I Do Not Agree

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.

Date*

Parent/Guardian Full Name*

Parent/Guardian Email*

Consultation

Upon submission of registration form, Rise and Thrive Inc. mentors will host a 30 minute consultation with the parent/parental guardian, then will host a 15 min consultation with our mentee of interest. Please disregard, if consultation has been arranged previously. The consultation will serve as a virtual meet and greet!

During the parent/parental guardian consultation: We will ask you a few questions regarding (areas of focus/concern, additional background that is helpful to serve as your child's mentor, situational circumstances, element(s) of desire, goal for private mentoring, child’s availability/non-negotiable dates).

Category: Registration

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$125 per session per 1 hour
Note: If you would like to register for more than 1 hour, please increase the quantity.

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