MENTEE APPLICATIONS | Midland.Center

Student First name

Student Last name

Birthday

Month

Day

Year

Grade

Address

Parent Name (First & Last)

Phone

Parent Email

Emergency Contact Name (if not parent)

Emergency Contact number (if not parent)

Allergies/Medical Concerns:

Check the traits that BEST describe your child:

Please list your child's favorite hobbies/activities:

My child will:

Walk home

If your child will be picked up, please list who has permission to pick them up.

I give permission for the aforementioned child to participate in the peer mentoring program at The Center. I understand the nature and rules of the mentoring efforts & reserve the right to withdraw my child from the program at any time.

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I hereby release The Center and its leaders from any liability in the event of accident or injury to my child.

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I understand that every effort will be made to contact me in case of emergency, but in the event that I cannot be reached, I authorize the treatment of this child by qualified medical personnel.

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By signing I also consent to allowing my child’s picture to be used by The Center and give my permission for my child to walk to The Center from school on Wednesdays with the Center’s staff.

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Today's Date

Month

Day

Year

MENTEE REGISTRATION (PEER MENTORING)