Fitness and

Mentorin
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Mentor Program: Authorization for Services

_________________________________________________give permission for my child,
, to participate in the Funhouse Commons Mentor Program
I understand that my participation in the program is completely voluntary and that I may terminate this authorization
at anytime. I understand that my consent is required for the Fitness and Mentoring to discuss or release any information about me or my family to agencies and individuals. (Exception: mentors and Fitness and Mentoring staff are
required by law to report any known or suspected child abuse or neglect, or if anyone life is in danger). I understand
that I can have a copy of this consent form upon request and may terminate this consent in writing at any time.

Mentor Program: General Hold Harmless

In the event of any injury, I authorize a qualified physician to examine the above named child and to administer emergency care and to arrange for any consultation by a specialist that he/she deems necessary to insure proper care of
the injury. Every effort will be made to contact the parent or guardian to explain the nature of the problem prior to any
treatment.
In the event it becomes necessary for the Fitness and Mentor staff or my child's mentor to obtain emergency care for
him/ her, neither the Mentor, the Fitness and Mentor staff assumes any financial liability for expenses incurred because
of accident, injury, illness, and/or unforeseen circumstances. I also understand that accidents may happen that result
in physical or emotional injury, paralysis or death as well as damage to property or to third parties. I agree to hold
harmless The Fitness and Mentor program, its staff, its board of directors, and the mentor harmless should any such
accident occur.

Signature___________________________________ Date___________________________________

Mentor Program: Parent/Guardian Application

Parent/Guardian Name:_______________________________________________________________________
Child's Name:____________________________________________Birthdate________Age________Sex_________
Mailing Address___________________________________________________________________________
Physical address (if different):__________________________________________________________________

State:_______________Zip:________________Day Phone:_______________Evening Phone:__________________

email:_________________________________
Emergency Contact (name and phone):___________________________________________________________

Please Check One:

Please check those that apply:

_______Single parent household

Qualify for free/reduced lunch at public school

_______Dual parent household ______________________Don't attend public school

_______Multi-generational household _________________English is second language in home

Briefly describe your child in terms of his or her personality, strengths, weaknesses and interests. Include and physical, mental or
emotional health issues.

W have you decided to pursue mentorship for your child?

What does your child think about having a mentor?

What sort of person do you think would be a good mentor for your child?

Does the child have any allergies or medical conditions?

ACTIVITY
BASEBALL
SOCCER
BASKETBALL
RACQUETBALL
GOLF
ARCHERY
TENNIS
VOLLEYBALL
BIKE RIDING
SKATEBOARDING
SNOWBOARDING
SKIING
I CE SKATI NG
ROLLER SKATING
GYMNASTICS
PING PONG
BOWLING
BADMINTON
FRISBEE
FLYING
BEACH WALKING
GARDENING
WADING
FUNNING
HORSEBACK RIDING
CAMPING
BOATING
Ra-IING
SAILING
SWIMMING

Love it

Like it

Not so
much

ACTIVITY
WOODWORKING
AUTOMOTIVE/ ENGINES
MODES
LEGOS
COOKING
BAKING
VVEAVI NG
SEWING
EMBROIDERY
CROCHETING
KNITTING
DRAWING
FAINTING
CRAFTS
SINGING
MUSIC
DANCING
DRAMA
MUSEUMS
READING
WRITING
COMPUTERS
VIDEO GAMES
BOARD GAMES
CROSSWORDS
ANIMALS
MOVIES
MARTIAL ARTS
IMPROV
OTHER

Please describe any other hobbies or interests your child has:

LOVE IT

UKE IT

NOTE)
MUCH

Mentor Program: Ground rules for

parents/guardians
Make sure your child attends all of his or
her scheduled Saturdays. In the case of
sickness, travel, or any change of plans,
notify the mentor as soon as possible.
Your child is allowed to miss only 1 Saturday without needing
an excuse
If you feel the mentorship should end, please contact me
directly immediately. The dosing of a mentorship needs to
be handled with care to avoid misunderstandings, hurt
feelings and confusion.
Please do not prevent your child from seeing their mentor as
punishment. This relationship is intended to cultivate a
helpful relationship with a caring adult; it is not intended to
be a reward" for good behavior.
Please do not discuss your child with the mentor in the
child's presence. If there is something the mentor should
know, tell him or her when the child is out of range.
Please make sure your child wears their shirt every
weekend

PLEASE REVI EW THE FOLLOWING WITH YOUR CHILD, MAKING

SURE TH EY UNDERSTAND WHAT THEY ARE AGREEING TO. WHEN
YOU ARE CONFIDENT YOUR CHILD UNDERSTANDS, ASK THEM TO
SIGN THE DOCUMENT

Signed________________________________________ Date___________________________