Em2g Mentorship Registration Form

Mentee Information

Mentees Name

First NameLast Name

Birth Date

MonthDayYear

Grade

Gender

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Name

First NameLast Name

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number

E-mail

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Does your son/ daughter have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the Mentee prescribed an inhaler or Epi-pen? If yes, please explain any instructions.

Please tell us a little about your son/ daughter .Ex: Interests, Behavior Concerns or any other information you consider important.

What would you like him/ her to gain from becoming a part of EM2G/ EL2G Mentorship?

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Extraordinary Men Mentoring Group/ Extraordinary Ladies Mentoring Group during the selected camp. In exchange for the acceptance of said child’s candidacy by Extraordinary Men Mentoring Group/ EL2G., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Extraordinary Men Mentoring Group/ EL2G, and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Extraordinary Men Mentoring Group/ EL2G including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports/camp activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named camper, Permission is hereby granted to to the Extraordinary Men Mentoring Group/ Extraordinary Ladies Mentoring Group and its affiliates including Directors, Coaches, and Volunteers to provide/seek the needed emergency treatment prior to the child’s admission to the medical facility.This authorization is granted only after a reasonable effort has been made to reach me.

Release authorized on the dates and/or duration of the registered camp season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

EM2G/EL2G Mentorship Registration