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

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* 1. First Name

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* 2. Middle Name

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* 3. Last Name

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* 4. Birthday

Date

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* 5. Gender

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* 6. Address/City/State/Zip

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* 7. Home Phone number

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* 8. Cell Phone

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* 9. Email

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* 10. Mother's (or Guardian) Full Name

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* 11. Phone number

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* 12. Mother's Address, if different or Email Address

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* 13. Father's Full Name

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* 14. Phone number

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* 15. Father's Address, if different or Email Address

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* 16. School Name & Address

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* 17. Grade (2025-2026)

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* 18. Emergency Contact (Full Name)

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* 19. Phone number

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* 20. Medical Insurance Carrier

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* 21. Policy #

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* 22. Does your student have any medical conditions or any prescribed medications? Please list.

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* 23. Does your student have any mental health diagnoses? Please list.

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* 24. Special education status (i.e., IEP or 504 plan)

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* 25. What is your student's free lunch eligibility status?

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

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

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* 28. Did your student attend an out-of-school time program last year?

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

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* 30. 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.

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* 31. 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

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* 32. I was referred by: ( First and Last Name )

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