Get a Mentor | Blueprint 58

Step 1 of 7

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Student School Information
Name*
First Last
Age*
Please enter a value between 0 and 99.
Date of Birth*
MM
DD
YYYY
Gender*
Current School*
Current Grade*
Home Room Teacher*
Section

Household Information
Primary Caregiver's Name*
Prefix First Last
Secondary Caregiver's Name
Prefix First Last
Address*
Street Address Address Line 2 City State Zip
Primary Phone*
Email
Language Spoken In Home*
Please list all people in the household, including name, age, and relationship to child:*

More About Your Student
What school/community activities does your child participate in?*
What special interests or hobbies does your child have?*
Please state any specific problems your child has at home or in school? Please explain. (i.e. anger problems, medical issues, etc.)*

Student's Responsibility
a. Attend classes, complete homework assignments, study and prepare for tests and examinations, and maintain a 70% or above grade average in all classes. b. Remain a student in good standing and receive no more than five (5) referrals to the Principal in a year. c. Participate in Blueprint 58 activities. d. Participate in two community service projects per year. e. Exhibit positive behavior in and out of school that helps and does not hamper the Student’s education. Continual disregard for the rules, regulations, and laws of the Blueprint 58, APS, the City, the County, or the State may cause expulsion of the Student from the program. Any decision to expel a Student from the program will be made solely by Blueprint 58.
Student Signature*
Today's Date*
Parent's Responsibility
a. Communicate with Blueprint 58, the Mentor Coordinator and the Student’s volunteer mentor on the following matters: (1) Scholastic achievements or problems, (2) Behavioral achievements or problems, (3) change of address or phone number and, (4) Positive or negative changes that are affecting the Student, his/her home life or environment. b. Notify (or hold the Student responsible to notify) all involved people in advance if the Student or Parent/Guardian is unable to attend previously scheduled activities, c. Support and encourage the Student to develop a positive relationship with the school, Blueprint 58, the Mentor Coordinators and the volunteer mentors. d. Agree to abide by all Blueprint 58 guidelines.
Parent Signature*
Today's Date*

Parent/Guardian Approval Release
The Parent/Guardian hereby agrees to the Student’s participation in the Program and attendance at all activities sponsored or recommended by Blueprint 58 during the term of the Program. The Parent/Guardian also agrees that the Student may attend team meetings relating to topics which may be deemed sensitive, such as alcohol and substance abuse, peer pressure, religion, self—esteem, postponing parenthood until marriage, and the importance of honesty, discipline, hard work and personal responsibility. In return for the student being permitted to take part in the activities sponsored or recommended by Blueprint 58 and the benefits the student will receive, from taking part in these activities, the parent/guardian on behalf of himself/herself and on behalf of the student, hereby fully and forever relieves, releases and discharges the Blueprint 58 Mentor, its directors, officers, employees and volunteers, and all persons assisting in these activities from any and all liabilities, claims or expenses arising from any injury or loss suffered by the student or parent/guardian, while traveling to or from, attending, or taking part in activities sponsored or recommended by Blueprint 58. The parent/guardian agrees to indemnify and hold all of the parties described above harmless from and against all claims, costs, expenses and liabilities incurred by them which result from any claim against them, asserted by or on behalf of, the student or the parent/guardian, including any claim made against them based upon their negligence or gross negligence.
Waiver
The Student and Parent/Guardian understand that Blueprint 58 has a legitimate interest in protecting the safety of all participants, including the Student, the Student’s volunteer mentor, other Students and volunteers, Mentor Coordinators and other Blueprint 58 employees (collectively, the “Participants”). Accordingly, the Student and the Parent/Guardian hereby authorize Blueprint 58 to contact third parties, including the Atlanta Public Schools, the Atlanta Police Department, and other agencies and offices, for information relating to the Student, and hereby consent and agree to the release of such information by such third parties to Blueprint 58. The Student and Parent/Guardian understand that Blueprint 58 may terminate the Student’s participation in the Blueprint 58 Program and activities based on information supplied to it by such third parties if, in Blueprint 58 ’s sole judgment, such information indicates that the Student has breached this Agreement or that the Student’s continued participation in Blueprint 58 ’s Program or activities may pose a threat to the Participants.

Emergency Contact # 1
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Work Phone
Relationship*
Emergency Contact # 2
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Work Phone
Relationship*
Emergency Contact # 3
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Work Phone
Relationship*

Signatures
This Agreement embodies the entire Agreement between the parties hereto, and supersedes all prior Agreements and understandings relating to the subject matter hereof.
Parent's Signature
Today's Date

Mentored Student Application

Step 1 of 7

Student School Information

Household Information

More About Your Student

Student's Responsibility

Parent's Responsibility

Parent/Guardian Approval Release

Waiver

Emergency Contact # 1

Emergency Contact # 2

Emergency Contact # 3

Signatures