bdc building bridges mentorship

application

Event Participant information

Name of Youth Participant:

Address

City:

State:

Telephone Number:

Email:

Parental Permission and Release of Liability

Medical Emergency Authorization and Health Information I authorize the program coordinator(s) to take such action as seems appropriate to protect the health and physical well-being of the above participant. This authority extends to any physician(s) selected by the program coordinator(s) to perform medical procedures including examinations and tests necessary to preserve the health and physical well-being of the above named participant. All efforts will be made to contact the parent(s) or guardian(s) in case of emergency.

Name of Parent or Guardian (please Initials):

Medical Emergency Authorization and Health Information

I authorize the program coordinator(s) to take such action as seems appropriate to protect the health and physical well-being of the above participant. This authority extends to any physician(s) selected by the program coordinator(s) to perform medical procedures including examinations and tests necessary to preserve the health and physical well-being of the above named participant. All efforts will be made to contact the parent(s) or guardian(s) in case of emergency.

Name of Parent/Guardian

Email Address

Primary Phone Number

Secondary Phone Number

Health conditions

The following information is provided as an aid to the event coordinator(s) in dealing with the well-being of the participant. The participant has the following health conditions: (include allergies, handicaps, diabetes, pregnancy, asthma, medications needed, etc.).

Name of Parent or Guardian (please Initials):

Pick-Up Authorization

In addition to the parent/guardian(s)/emergency contact listed above, please list the names of any possible persons authorized to pick up the above referenced youth participant

Name of Parent/Guardian

Relationship to Participant

Primary Phone Number

Secondary Phone Number

Authorization for Self-Checkout (For Participants Ages 14 or Older)

Program participants will only be released at the scheduled program ending times, or times designated to the program by the parent/legal guardian. Please select from the check-out options listed below.

OPTIONS

I do not grant my child permission to self-checkout from this program. Only the individuals listed above are authorized to pick-up and sign-out my child. will not be escorting my child to and/or from the program and grant my child permission to travel to and/or from the program and check-out independently at the conclusion of the program.

Name of Parent/Guardian

Youth Program Code of Conduct

The primary purpose of the Youth Program Code of Conduct is to ensure the safety and well-being of all participants at events and activities hosted by the BDC Youth Mentoring Program. It applies to all participants, including minors, their parents, and volunteers.
As a participant in this program, I will:

Conduct myself in a courteous manner and treat members, parents, volunteers, staff, and others with respect. Appropriate language and behavior are expected at all times.
Respect and adhere to the rules and guidelines of the program including all those specific to this event or activity.
Uphold an individual’s right to dignity by supporting an environment of inclusion which welcomes involvement of participants from all backgrounds.
Obey local, state and federal laws.

I understand if I fail to adhere to the above Code of Conduct, I will be subject to disciplinary action and potentially prohibited from attending and participating in this program.

I have been given a copy of the rules for this event and agree to abide by them. I have conveyed this information to the youth participant for which I am responsible

Name of Event Participant

Date

Name of Parent/Guardian

Date

Media Policy and Release

The BDC Building Bridges Mentoring Program may promote programs and activities involving minors through various media. This includes, but is not limited to newsletters, brochures, and social media. In doing so, the names and photos of members may be included to help tell the story.

Media Options

No, do not use my individual picture for any purpose. I will make an effort to avoid opportunities to be in group photos. No, do not use my name for any purpose