Parent/Mentee Interest Form

Mentee Name

First Name

Last Name

Date of Birth

YYYY

Age

Ethnicity

Parent/Guardian Name

Street Address

City

State

Zip

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Email Address

Current School they attend

Grade

Emergency Contact Name

Emergency Contact Phone Number

(###)

###

####

What are your expectations for Reality Check Mentoring Program:

Is your child available to attend our program on the 2nd and 4th Saturday of each month?

Yes

Describe your child’s school performance including grades, homework, attendance, behaviors, etc.:

Is your child currently having any problems either at home or school?

Has your child experienced any traumatic events (i.e., death in the family, abuse, divorce)? If yes, please provide details.

Section

Name of Primary Care Physician:

First Name

Last Name

Name of Primary Care Physician Phone No.:

(###)

###

####

Medical Insurance Provider:

Policy Number:

Medical Insurance Provider Phone No.:

(###)

###

####

Does your son have any physical problems or limitations?

Is your son currently receiving treatment for any medical issues?

Is he currently on any type of medication? If so, please specify.

Does your son have any known allergies or adverse reactions to medications? If yes, please describe them below:

Do you have reliable transportation?

Please read each of the following and sign below to confirm:

I give my informed consent and permission for my child to participate in the Reality Check Mentoring Inc. program and its related activities.

I hereby acknowledge that my child will be transported by his/her mentor and/ or Reality Check Mentoring Inc. staff or representatives while participating in the program, and that such transportation is voluntary and at his/her own risk.

I release Reality Check Mentoring Inc. of all liability of injury or other damages to me, or my child that may result from his participation in the program, including but not limited to transportation, and hold harmless any Reality Check Mentoring Inc. 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 agree to allow Reality Check Mentoring Inc. to use any photographic image of my child taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.

Nondiscrimination Policy: Reality Check Mentoring Inc. does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, height, weight, physical or mental ability.

First Name

Last Name