Apply for Our Emerging Leaders Program

Parental Consent
Please read this carefully before signing Concerned Black Men of Los Angeles Mentoring Program appreciates you and your son’s interest in his/her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their son to participate in the Concerned Black Men of Los Angeles Mentoring Program. After receiving this completed application from you, we will evaluate the information and send you a letter letting you know if your son has been accepted into the mentoring program. Much of the information you supply in this application packet will be used to match your son with an appropriate mentor. Therefore, the mentoring staff may, at times, need to access and share this information with prospective mentors and other parties when it is in the best interest of the match. However, we do not reveal names until there is an initial interest from the mentee, parent/guardian, and mentor based first upon anonymous information provided about each other.
Please check each of the following and sign where indicated:*
- I give my informed consent and permission for my son to participate in the Concerned Black Men of Los Angeles Mentoring Program and its related activities.
- I agree to have my son follow all mentoring program guidelines and understand that any violation on my or my son’s part may result in suspension and/or termination of the mentoring relationship
- I hereby acknowledge that my son will be transported by his/her mentor while participating in the Concerned Black Men of Los Angeles Community Mentoring Program, and that such transportation is voluntary and at his/her/our own risk.
- I release the Concerned Black Men of Los Angeles Mentoring Program of all liability of injury, death, or other damages to me, my son, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any Concerned Black Men of Los Angeles mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.
- I agree to allow Concerned Black Men of Los Angeles to use any photographic image of my son taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.
- I agree to allow Concerned Black Men of Los Angeles to see my child's academic transcripts and school grades.
By writing your name below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.*
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Emerging Leaders Application Form

Step 1 of 3

Parent/ Guardian

Leader's Information

Perspective Emerging Leader's Commitment

Parental Consent