Student Application

Step 1 of 7

Student Information
Name*
First Last
Age*
Please enter a number from 0 to 99.
Date of Birth*
Month
Day
Year
Gender*
Current School*
Current Grade*
Home Room Teacher*

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?*
What is your students favorite type of food?*
Does your student enjoy sports? If so, which ones in particular?*
Does your student enjoy more creative activities such as music, art, drama, etc? If so, which ones are their favorite?*
What does your student like to do most in their free time?*
Is there an activity that your student has always wanted to try but hasn't been able to?*
Please state any specific problems your child has at home or in school? Please explain. (i.e. anger problems, medical issues, etc.)*
Mentor Prefences
Do you have any preferences regarding your student's mentor? (i.e. Race, Gender, Age, etc.)*

Student's Responsibility
a. Be respectful. b. Be open to learning new things. c. Be open to sharing your favorite things with your mentor (interests, things in your community etc) d. Communicate any challenges with your parent.
Student Signature*
Today's Date*
MM slash DD slash YYYY
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. Let your mentor or mentor coordinator know if you are unable to attend previously scheduled activities. c. Support and encourage the Student to develop a positive relationship with their mentor. d. Agree to abide by all Blueprint 58 guidelines.
Parent Signature*
Today's Date*
MM slash DD slash YYYY

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. Parent/Guardian authorizes the Released Parties to transport Participant to and from Blueprint 58 affiliated events and activities, with the understanding that all staff and Volunteers/Mentors for Blueprint 58 have undergone a background check as well as a motor vehicle record check. The driver is responsible for carrying valid liability insurance, operating the vehicle in a safe manner and for maintaining the vehicle in a safe working condition. Parent/Guardian is fully aware of and accepts the special dangers and risks inherent in the operation of a motor vehicle, including physical injury, death or other consequences that may arise or result directly or indirectly from operation of a motor vehicle. Media Release. Participant and Parent/Guardian grants and conveys to Blueprint 58 all right, title and interest in any and all photographic images and video or audio recordings made by or for Blueprint 58 during Participant and Parent/Guardian’s participation in the Activities, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.

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
MM slash DD slash YYYY

STUDENT APPLICATION

Step 1 of 7

Student Information

Household Information

More About Your Student

Mentor Prefences

Student's Responsibility

Parent's Responsibility

Parent/Guardian Approval Release

Waiver

Emergency Contact # 1

Emergency Contact # 2

Emergency Contact # 3

Signatures