AFTER-SCHOOL / WEEKEND

MENTORSHIP APPLICATION

Participant's First Name

Participant's Last Name

Participant's Middle Initial *

Participant's Current Age *

Date of birth *

Participant's Grade in School *

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

College

What School Does He Currently Attend? *

Participants Cell Number *

Participants Email *

Can We Text / Email Participant? *

Yes

No

Participant's Program Interest? *

Mental Health
Meditation & Mindfulness
Health & Wellness
Weapon Safety
Chess/Cristical Thinking
Reading and Writing Tutoring
Math Tutoring
Fitness Training
Financial Literacy
Baseball
Weapon Safety
Creative Writing/Filming
Engineering and Recording Art
Automotive Repairs
Culinary Arts
Meditation & Mindfulness
Semi Trucking
Home Improvements
Barber Skills
Hair Braiding
Esthetician
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Home Address *

State *

City *

Zip Code *

Parent/Guardian First and Last Name *

Parent/Guardian E-mail Address *

Home Phone

Work Phone

Cell Phone *

Can We Text / Email the Parent/Guardian? *

Yes

No

Emergency Contact First/Last Name *

Emergency Contact Phone Number *

Relation to Participant *

Please list any food or other types of allergies the student has. *

Does the student require use of any medication? *

Yes

No

If yes, does the student know how to self-administer their medication?

Yes

No

Please provide any details or comments about why you want your son to be apart of our organization. (Include any behavioral or disciplinary issues that may help us better serve you). *

Student's T-Shirt Size *

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XLarge

Adult 2XLarge

Adult 3XLarge

Are you able to provide transportation for your child to and from activities? *

Yes

No

Would you be interested in helping other parents carpool? *

Yes

No

Do you have the ability to download and use the Band.us app? That is our main medium of communication and will be hard for your son to participate without a parent in the Band app. *

Yes

No

Media Release :

Please read and accept the following

By selecting "I Accept," you acknowledge that you have read and accept the following statement. I grant AYAC permission to use my likeness in photographs, video recordings, or electronic images in any and all of its publications, including website entries, without payment or any other consideration. *

I Accept

Release and Waiver:

Please read and accept the following

By selecting "I Accept," you acknowledge that you have read and accept the following statement. I hereby release, discharge, and hold harmless AYAC, its officers, directors, employees, volunteers, agents, representatives, and affiliates from all claims, demands, actions, suits, losses, costs, charges, injuries, damages, liabilities, obligations, tax assessments, penalties, or expenses of any kind or nature whatsoever, whether direct or indirect, known or unknown, foreseen or unforeseen, arising out of my participation in [any AYAC programs/activities]. *

I Accept

Assumption of Risk

Please read and accept the following

By selecting "I Accept," you acknowledge that you have read and accept the following statement. I understand and acknowledge that participation in [this mentorship] may involve inherent risks, dangers, and hazards, including but not limited to specific risks related to the activity, e.g., "physical exertion, contact with other participants, changing weather conditions". I am fully aware of these risks and hereby assume all risks of injury, illness, or death, and all responsibility for damages, losses, costs, and expenses. *

I Accept

Hold Harmless Agreement:

Please read and accept the following

By selecting "I Accept," you acknowledge that you have read and accept the following statement. As a lawful parent/guardian of the above-named student, I hereby give permission for my child to participate in AYAC sponsored extracurricular activities/programs. I agree that I have fully read, understand, and agree to the conditions set forth below, and submit such choice as a binding signature of agreement: I acknowledge and agree that, during AYAC sponsored activities, my child will be subject to any and all AYAC disciplinary rules and Student Code of Conduct to which he is subject during the school day. I further understand that my child will be subject to the supervision and direction of those who accompany the students on behalf of AYAC. I consent for/to my child's participation in extra-curricular activities. I acknowledge and agree that I am responsible for informing appropriate school personnel of any medical actions they believe necessary for my child until such time as I may be contacted. I acknowledge and agree that AYAC, its officers, employees, agents and volunteers do not have or assume any liability for damages, losses, or injuries to the above-named student as a result of the student participating in this activity. Acknowledge and agree that any revocation permission given by this form can only be in writing and must be delivered to the appropriate school officials to be effective *

I Accept

Medical Treatment:

Please read and accept the following

By selecting "I Accept," you acknowledge that you have read and accept the following statement. I hereby grant AYAC permission to administer or seek any necessary medical treatment for me in the event of an emergency. I agree to be financially responsible for any costs incurred due to such treatment. *

I Accept

Choice of Law

Please read and accept the following

By selecting "I Accept," you acknowledge that you have read and accept the following statement. I understand that the law of the State of FLORIDA will apply to this contract. I HAVE CAREFULLY READ AND UNDERSTAND ALL PROVISIONS OF THIS RELEASE, AND FREELY AND KNOWINGLY ASSUM THE RISK ON BEHALF OF MYSELF AND MY CHILD AND WAIVE MY RIGHTS CONCERNING LIABILITY AS DESCRIBED ABOVE *

I Accept

Acknowledgment:

Please read and accept the following

By selecting "I Accept," you acknowledge that you have read and accept the following statement. I have carefully read this release and waiver of liability and fully understand its contents. I am aware that this is a complete release of liability and binding contract between myself and AYAC and sign it of my own free will. *

I Accept

Parent's Signature *

Printed Name (Parent) *

Date: *

By selecting "I Accept," you acknowledge that you have read and accept the following statement. *

I Accept