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I AM A KEEPER Mentoring & Life Skills Application

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
1.First Name (Required)(Required.)
2.Middle Name (Required)(Required.)
3.Last Name (Required)(Required.)
4.Birthday (Required)(Required.)
MM/DD/YEAR
5.Gender (Required)
6.What is your child's racial and/or ethnic identity?
7.Is your child an English learner or English as a second language student?
8.Address/City/State/Zip (Required)(Required.)
9.Home Phone number (Required)(Required.)
10.Cell Phone(Required.)
11.Email (Required)(Required.)
12.Mother's (or Guardian) Full Name (Required)(Required.)
13.Phone number (Required)(Required.)
14.Mother's Address or Email Address if different (Required )
15.Father's Full Name
16.Phone number
17.Father's Address or Email Address (if different)
18.What grade level will your child be entering this school year (2026-27)? (Required)(Required.)
19.Current School for the 2026-2027 school year. (Required)(Required.)
20.Please share the ZIP code of the school your child attends.
21.Emergency Contact (Full Name-Required)(Required.)
22.Phone number (Required)(Required.)
23.Medical Insurance Carrier ( required )(Required.)
24.Policy #
25.Does your student have any medical conditions or any prescribed medications? Please list. (Required)(Required.)
26.Does your student have any mental health diagnoses? Please list. (Required)(Required.)
27.Special education status (i.e., IEP or 504 plan-Required)(Required.)
28.What is your student's free lunch eligibility status? (Required)(Required.)
29.What are your student's extracurricular hobbies and interests?
30.How did you hear about the My Sister's Keeper & My Brother Keeper I AM A KEEPER youth program?
31.I, the 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 all field trips. I give consent for my child to be photographed, videotaped, and participate in marketing, advertising, and promotions. 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 70%) 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, your child's full name, and the date in the box below to serve as your signature and consent for your child's participation.(Required.)
32.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, used only by authorized personnel within the organization, and shared with our funders and evaluation partners. Sign your name below(Required.)
33.I was referred by: ( First and Last Name ) (Required Answer ). If not referred by someone, put N/A
34.This program is free for low to moderate income families. What is your household income*(Required.)
35.What is your household size?(Required.)