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Student Information


Parental & Guidance Information

Are there 2 parents and/or guardians?

Emergency Contact

(Please identify a person other than the parent(s)/guardian(s) listed above; attempts to contact parent(s)/guardian(s) will be made before contacting Emergency Contact.)

General Information

Student's Availability (days of the week and times of day)

What is level of interest in participating in MentorMe opportunity (Scale of 1 – 10; 1 not really interested; 10 very interested)

Student Interest Level
Parent / Guardian Interest Level

Health Information

Medical Acknowledgment

I represent that the Student does not have any health or physical problems or limitations that will interfere with participating in the MentorMe program, other than those specifically described above. If emergency medical procedures or treatments are required during participation, I hereby authorize and consent for a MentorMe Representative to administer, arrange for, or consent to medical procedures or treatments at his/her discretion, including any related transportation. I understand the parent/guardian or emergency contact listed above will be contacted as soon as possible. I authorize and give consent for the Student to receive over-the-counter medication such as ibuprofen, acetaminophen, antidiarrheal medication, antibacterial ointment, hydrocortisone cream, throat lozenges, eyewash solution, and similar items unless specifically prohibited above under Medical Information.


(Please attach a copy of the medical insurance card.)

Medical Insurance

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Other Insurance. I understand that MentorMe may not have insurance coverage specifically applicable to injuries or damage(s) to a Student or his/her property. I represent that Student has insurance coverage in the event of an accident, injury, or damage.


Media Authorization. I consent to the use of Student’s photograph/video or likeness in any MentorMe printed or electronic publications, including websites, and I waive the right to inspect or approve the publications unless specifically prohibited in writing by Student’s parent(s)/guardian(s). I release and hold MentorMe harmless from all claims, demands, and causes of action related to Student’ photographs/videos or likeness in MentorMe publications.

General Authorization, Waiver, and Release. I hereby authorize Student to participate in the MentorMe program, and I acknowledge and accept risks associated with participation in such programs, including any involved transportation. I acknowledge, understand, and agree that participation in MentorMe opportunities may involve inherent risks to Student and may result in injury including, but not limited to, sickness, personal or emotional injury, death, property damage, and/or financial damage. I agree to accept financial responsibility for any injury, loss, and/or other damage sustained during participation, as well as for any medical procedure or treatment rendered to the Student that is authorized by a MentorMe Representative. I assume full responsibility for the Student’s actions and injuries, regardless of cause.


I hereby agree to release, defend, indemnify, and hold harmless MentorMe, including its governing board, officers, directors, leaders, mentors, guides, employees, agents, and representatives (collectively 'Representatives') from and against any and all actions, causes of action, liabilities, charges, claims, damages, losses, costs and/or expenses, including reasonable attorney’s fees, commenced, requested, or assisted by me, my family members, or anyone else acting on Student's behalf or my behalf arising out of Student's participation with MentorMe opportunities, related transportation, or the rendering of emergency or other medical procedures or treatments, if any, except if caused by Representative's gross negligence or willful and wanton misconduct. Severability. Any provision or portion of this Agreement that is found to be illegal, unconscionable, or void shall be reduced in scope to the maximum enforceable level. Such void provision or portion shall not have any effect on the Agreement as a whole, and the remainder of the Agreement shall be binding on the parties.

Applicable Law. This Agreement shall be construed in accordance with and governed by the laws of the State of Michigan without regard to its conflict of law principles.


I consent to the Student being placed with a Christian Mentor and agree to fully support MentorMe’s ministry. I acknowledge and agree that MentorMe has the right to terminate Student’s participation at its sole discretion because of Student’s behavior, health, and/or physical condition and that such decision is final. The Student is responsible for any cost(s) associated with the termination of participation or of returning Student home.


Is Student under 18 years of age?

MentorMe is a Christian organization which requires all those representing its ministry to honor Jesus Christ and model his Gospel in all they do and say.

Thanks for submitting!

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