Mentee Funding Application | CBMLA CARES Application

MEDICAL AND GENERAL LIABILITY RELEASE
As the parent/authorized guardian of the above named youth, I hereby release Concerned Black Men of Los Angeles (CBMLA) and CBM CARES Los Angeles, CA of all liability of injury, death, or other damages to me, my child, family, estate, or heirs, that may result from his/her participation in the program, including but not limited to those related to transportation, and hold harmless any CBM mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined. In case of an emergency, I give permission for CBM to seek medical treatment for my son, In case of emergency please contact the following:
EMERGENCY CONTACT 1*
FIRST AND LAST NAME RELATIONSHIP PHONE NUMBER
EMERGENCY CONTACT 2*
FIRST AND LAST NAME RELATIONSHIP PHONE NUMBER
MEDICAL PROVIDER/PHYSICIAN:
First Last
MEDICAL PROVIDER ADDRESS
Street Address City State / Province / Region ZIP / Postal Code
MEDICAL OFFICE PHONE
INSURANCE PROVIDER
NAME GROUP # ID NUMBER PHONE NUMBER
Is your child being treated for any medical conditions at this time? If yes, please explain treatments, including any medications:
Does your child experience any of the physical impairments listed below:
- HEARING IMPAIRMENT
- SEEING IMPAIRMENT
- PHYSICAL DISABILITY
Please use the space below to inform us about any and all important information concerning the health and physical/mental/emotional status of your child.
- SPECIAL EQUIPMENT
- WALKER
- WHEELCHAIR
- HEARING AID
- GLASSES/CONTACTS

PARENTAL CONSENT FORM
MENTEE NAME SCHOOL NAME
Please initial the following boxes and return.*
- I give my informed consent and permission for my child to participate in the CBM CARES® Los Angeles, CA Program and its related activities.
- I agree to have my child follow all mentoring program guidelines and understand that any violation on my child's part may result in suspension and/or termination of the mentoring relationship.
- I authorize CBM to obtain any needed information regarding my child from his school's staff, including academic and behavioral records and conversations with teachers, counselors, and other administrative staff.
- I hereby acknowledge that my child will be transported by his mentor and/or CBM staff or representatives while participating in with Concerned Black Men of Los Angeles and that such transportation is voluntary and at his/her own risk.
- I hereby acknowledge that my child will be transported by his mentor and/or CBM staff or representatives while participating in with Concerned Black Men of Los Angeles and that such transportation is voluntary and at his/her own risk.
- I release the Concerned Black Men of Los Angeles of all liability of injury, death, or other damages to me, my child, 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 CBM mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined. A separate Medical and Liability Release form which lists my son's medical history, emergency contacts and insurance information is attached with my signature.
- I agree to allow Concerned Black Men of Los Angeles to use any photographic image of my child taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.
- I agree to participate in the specified research studies and/or surveys, and give my consent for my child to participate.
- I hereby certify that all information provided on this application is true and complete. I understand that falsification or significant omissions of any information may be considered justification for non-acceptance or dismissal if discovered at a later date.
CBMLA Authorized Staff: Mark Anderson: President William McCuller: Director of Programs A. Rocky Cusseaux: Program Manager Maurice Buntin: Program Advisor
PARENT/GUARDIAN SIGNATURE*
First Last
Date
MM slash DD slash YYYY

Parent Permission for Release of Mentee Personal Information
- I hereby grant permission for Concerned Black Men of Los Angeles (CBMLA) to make contact with my child and conduct a personal interview for the purposes of becoming a CBM CARES® Los Angeles, CA mentee. CBM may also make contact with my child on school premises to conduct all school and program related business as well as to provide ongoing support of his participation in the mentoring program.
- I authorize CBMLA to obtain any needed information regarding my child from his school's staff, including academic and behavioral records and conversations with teachers, counselors, and other administrative staff.
- I understand that basic information about my child will be anonymously (without names) shared with prospective mentor(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my and my child's identity and other relevant information will be shared with the mentor to the extent it aids in facilitating a successful match.
CBM authorized staff: Mark Anderson: President William McCuller: Director of Programs A. Rocky Cusseaux: Program Manager Maurice Buntin: Program Advisor
PARENT/GUARDIAN SIGNATURE*
First Last
Date
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

CBMLA CARES MENTEE APPICLATION

Step 1 of 5

CONTACT INFORMATION

SCHOOL INFORMATION

Student Health/Wellness

Family Household Information

MEDICAL AND GENERAL LIABILITY RELEASE

CBMLA CARES APPLICATION

CBMLA CARES MENTEE APPICLATION

Step 1 of 5

CONTACT INFORMATION

SCHOOL INFORMATION

Student Health/Wellness

Family Household Information

MEDICAL AND GENERAL LIABILITY RELEASE