Beyond the Bell Group Mentorship

Youth Information

Please note all information remains confidential

Student Name*

First Last

Gender*

Male
Female
Other

Date of Birth*

MM/DD/YYYY

Grade*

What school does the Student attend?*

Address*

Street Address City Province Postal Code

Parent/Guardian Information

Main Contact: Parent/Guardian Name*

First Last

Parent/Guardian Home Phone*

Parent/Guardian Cell Phone*

Parent/Guardian Email*

Address*

Street Address City Province Postal Code

Alternate Parent/Guardian Name*

First Last

Alternate Parent/Guardian Home Phone*

Alternate Parent/Guardian Cell Phone*

Alternate Parent/Guardian Email*

Emergency Contact

Emergency Contact*

First Last

Phone*

Relationship to Youth*

Participants Medical Information

Please provide any relevant medical diagnosis that the mentor should be aware of:*

How would your child benefit from having a mentor?

Please list details of how they would benefit from having a mentor?*

Please provide at least 2 goals for the child/youth (ex. friendship skills, self-esteem, etc.)*

Release of Liability and Assumption of Risk Waiver

Release of Liability and Assumption of Risk Waiver*

I understand that the YMCA of Regina assumes no responsibility for injuries or illnesses which I, my spouse/partner, or my minor children or any other person may sustain as a result of my/their physical condition, this program, my/their use of any facility or my/their participation in any activities, programs, exercise, or use of any equipment (collectively, “Activities”). I expressly acknowledge on behalf of myself, my spouse/partner, my minor children and our heirs that I assume the risk for any and all injuries, illnesses, death, loss or damage which may result from any of the foregoing. I herby release and discharge the YMCA of Regina, its agents, servants, and employees from ay and all claims for injury, illness, death, loss or damage which I, my spouse/partner, or minor children may suffer as a result of their physical condition, this program, the use of any facility, or participation in any Activities. Participants are prohibited from possessing or using alcohol, tobacco products, non-prescription drugs, and weapons of any kind. Participants must follow safety instructions of YMCA staff, and refrain from harmful behavior. Failure to comply with thes YMCA policies will result in immediate dismissal from YMCA programs without refund.*

Consent*

I consent to receiving communications from the YMCA Mentorship Coordinator with regards to programming and schedules. You may withdraw our consent at any time by contacting jill.lesuk@mjymca.ca*

Consent*

I understand that the YMCA of Regina is not responsible for personal property lost or stolen while members and/or program participants are using YMCA facilities, or are on YMCA premises.*

Consent

I give my permission to the YMCA of Regina to use indefinitely, without limitation or obligation, photographs, film, footage, or tape recordings which may include my, my spouse/partner’s or minor children’s image or voice for purposes of promoting or interpreting YMCA Programs.

Acceptance

Consent*

I acknowledge the Liability Waiver set forth above and being in agreement with the Mission and Goals of the YMCA, hereby apply for registration*

Consent*

By checking this box and typing my name below, I am indicating my name below, I am indicating consent on this form.

Parent/Guardian Name for form consent*

(First and last)