Please provide the following information for youth desiring to participate in I AM A KEEPER Mentoring Programs.

ALL ANSWERS ARE REQUIRED FOR CONSIDERATION OF THE PROGRAM

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1. First Name (Required) (Required.)

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2. Middle Name (Required)

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3. Last Name (Required) (Required.)

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4. Birthday (Required) (Required.)

Date

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5. Gender (Required)

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6. What is your child's racial and/or ethnic identity?

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7. Is your child an English learner or English as a second language student?

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8. Address/City/State/Zip (Required) (Required.)

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9. Home Phone number (Required) (Required.)

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10. Cell Phone (Required.)

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11. Email (Required) (Required.)

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12. Mother's (or Guardian) Full Name (Required) (Required.)

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13. Phone number (Required) (Required.)

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14. Mother's Address or Email Address if different (Required )

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15. Father's Full Name

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16. Phone number

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17. Father's Address or Email Address (if different)

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18. What grade level will your child be entering this upcoming school year (2026-27)? (Required) (Required.)

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19. School attended for 2025-2026 school year (this past school year). If multiple, please write the school where they ended this past school year. Summer Program students MUST attend school in Wayne, Macomb, or Oakland counties. (Required) (Required.)

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20. Please share the ZIP code of the school your child attends. If multiple, please write the ZIP code where they ended the year.

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21. Emergency Contact (Full Name-Required) (Required.)

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22. Phone number (Required) (Required.)

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23. Medical Insurance Carrier ( required ) (Required.)

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24. Policy #

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25. Does your student have any medical conditions or any prescribed medications? Please list. (Required) (Required.)

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26. Does your student have any mental health diagnoses? Please list. (Required) (Required.)

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27. Special education status (i.e., IEP or 504 plan-Required) (Required.)

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28. What is your student's free lunch eligibility status? (Required) (Required.)

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29. What is your student's social media handle, if any?

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30. What are your student's extracurricular hobbies and interests?

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31. Did your student attend an out-of-school time program last year? ( 2025)

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32. How did you hear about My Sister's Keeper & My Brother Keeper? I AM A KEEPER youth program?

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33. I, parent/guardian (listed below), grant permission for my child (listed below) to participate in I AM A KEEPER youth mentoring programs. I hereby give my permission for my student to attend field trips. I give consent for my child to be photographed, videotaped, and participate in research for the purposes of promotion, program development, and program funding. Staff and affiliates may seek medical care for my child as needed or in the event of an emergency. I indemnify and hold My Sister's Keeper, My Brother's Keeper, B.A.S.S., Inc., its administrators, board, staff, mentors, volunteers, agents and partners harmless and NOT responsible or liable for any accident, incident, injury, or loss resulting from my child's participation. I waive my right to seek legal action or any form of recourse. I will ensure that my child fully and actively participates (at least 80%) to receive the maximum benefit from the program offerings. I also commit to parental involvement, supporting events and endeavors, and complying with the tenets, policies, and procedures of the program.
Type your full name, child's full name and date in the box below to serve as your signature and consent for your child's participation. (Required.)

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34. By signing my student up, I authorize this program to collect and use data about my child for the purposes of program development , safety , and improving educational outcomes. I understand that this data will be kept confidential , stored securely , and used by authorized personnel within the organization , and shared with Michigan Department of Lifelong Education , Advancement , and Potential (MiLEAP) 32n OST Grants Program and state evaluation partners. Sign your name below (Required.)

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35. Students who register for Summer Discovery programming must commit to attending programming throughout the summer. Summer Discovery is not a drop-in program, and it’s important for students to attend daily to receive the full benefits of the program. Will your student be able to attend at least 70% of the summer program days? Our program is 25 days, so this would mean attending 18 days. ( REQUIRED ) (Required.)

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36. I was referred by: ( First and Last Name ) (Required Answer ). If not referred by someone, put N/A

Please note: Along with assessments, your child will be asked to complete a post-survey after the program so that we can evaluate any program-related successes and challenges this year in order to continue to improve Summer Discovery to best serve all students and families. No further action is required to provide consent for your child to participate. If you would prefer that your child not participate, please notify SITE EMAIL ADDRESS confirming you would like to opt-out of student surveys.

By submitting this enrollment application, I, the parent/guardian, consent to be contacted by Summer Discovery administration and/or service providers. All questions must be answered to the best of your knowledge.

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