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* 1. Contact Information

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* 2. Child Information

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* 3. Why would you like your child to have a mentor?

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* 4. Does your child currently participate in any clubs, activities, or sports?

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* 5. What is your child's t-shirt size?

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* 6. Does your child currently have any health concerns or medical conditions that could be restrictive to activities with Emmaus Mentoring? Please check from the list below or fill in the blank if not listed:

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* 7. Do you have any other comments, questions, or concerns?

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* 8. Emergency Contacts
Name-Phone-Relation (i.e. Mary Chapman, 704-555-6666, Grandmother)

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* 9. Release Waiver
In consideration of my child’s participation in The Emmaus Mentoring Program I hereby agree on behalf of myself, my heirs, legatees, executors, administrators, and personal representatives, to release and hold harmless all staff, chaperones, and mentors associated with Emmaus and the Evangelical Lutheran Church in America, and any and all other persons and organizations assisting the Emmaus Mentoring Program from liability for any injury to my child, to my child’s property and any and all claims in any manner arising from or associated with my child’s participation. I understand in case of an emergency in which I am unavailable or cannot be contacted, the Emmaus Mentoring Program’s staff and mentors have my total permission to use their best judgment in matters of treatment.

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* 10. Media and Survey Release
I hereby grant to the Emmaus Mentoring Program to periodically administer surveys to me and my child. I also hereby grant the Emmaus Mentoring Program or any of its agents, the right and permission, with respect to surveys, photographs, and video which the Emmaus Mentoring Program or its agents have taken of me or my child(ren), or which I/we may be included with others, to copyright the same in its own name or otherwise: to use, re-use, publish, re-publish in the same in whole or part, in conjunction with any printed materials, illustration, promotion, art, and advertising. I have read the foregoing and fully understand the contents thereof.

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