Agape Youth Mentorship Application
What Is the Agape Mentorship Program?
Thank you for registering for our Mentorship Program! The Agape Mentorship Program is a volunteer program for any youth ages 7-17 in Lane County who have accessed our program due to having a family member incarcerated at any time in their life. Please fill out an individual form for each child. The program consists of the following mission and goals:
Mission: To facilitate the building of consistent, in-depth relationships between equipped adults and children of incarcerated family members. Through a deeper relationship with Jesus Christ, we hope to help empower Agape Youth with a sense of belonging and importance in their community while nurturing possibilities for a brighter future.
1. Share the gospel of Jesus Christ with all because we believe He is the real answer to all of life's needs.
2. Raise up disciples and therefore provide good Mentors as examples and establish long-term mentoring relationships.
3. Equip Youth through teaching and mentoring various aspects of life skills as applied through a biblical worldview.
4. Help Youth get plugged into a local church body and/or youth group.
5. Provide quality mentors who serve as healthy role models and develop long-term relationships that result in raising up disciples.:
-Avoidance of high-risk behaviors
If you have any questions don't hesitate to email at firstname.lastname@example.org
Child First and Last Name
Does your child currently reside in Lane County, Oregon?
(We are currently only accepting applications for children residing in Lane County.)
American Indian/Alaskan Native
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
2018-2019 School Year
What school will child attend?
2018-19 School Year
What are your child's favorite subjects in school?
What subjects does your child feel they may need help with?
Please list a few of your child's hobbies/interests. This will help their mentor with planning activities.
Does your child participate in extracurricular activities?
i.e. sports, clubs, dance, art etc.
Your Relationship to the Child
Parent/Guardian First and Last Name
Parent/Guardian Legal Relationship
Is the child in foster care?
Parent/Guardian Primary Phone
Parent/Guardian Cell Phone
(Email is our primary way of communication with you about updates and upcoming events.)
Additional Child Information
Who is/was incarcerated in relation to the child?
If selected "Other" please explain below.
If selected "Other" above, please explain here.
Is the person listed above currently incarcerated or were they previously incarcerated?
Where is/was the child's parent incarcerated
Current contact with incarcerated parent
Child is in regular contact with parent (visits, letters, calls)
Child has irregular contact with parent
Child does not have any contact with parent
What areas in their life would your child benefit in having a mentor?
i.e. academics, attending church, encouragement, support, someone trusted to spend time with, etc.
Does your child have any siblings that will also be applying for the mentorship program? If so, please provide their full name(s).
Please share any additional info you'd like for us to know about your family's situation.
Emergency Contact Information
This person will be contacted if the Parent or Guardian is unavailable.
Emergency Contact First and Last Name
Emergency Contact Relationship
Emergency Contact Cell Phone
Child Health and Medical Information
Name of child's physician
Phone of child's physician
What is the date of your child's last tetanus shot?
Please list any current medical conditions or concerns, or any recent injury.
Please list details and treatment for any known allergies marked above.
Does your child need a special diet?
If so, please provide information.
Special Considerations, Limitations, Needs or Behavioral Issues
To help set your child up for success, please share any additional information that would be pertinent for our staff/mentors to know. Please list below.
Medications and Dosage
Please include names of medications, times to be given and reason for each medication.
Please check yes or no for each of the following releases.
Permission for Activities
Your child and their mentor may get together for variety of activities to do in the community including, but not limited to, church events, youth events, sports events, local outreach, etc.
I, the parent, or legal guardian of the above child, hereby give permission for my child to participate in these activities.
I, the parent, or legal guardian of the above child, hereby give permission to Agape Youth staff and mentors to administer medications as listed above. I understand that it is my responsibility to provide prescription medication in original pharmacy containers or as labeled physician samples if it will be necessary to administer the medication during mentorship activities.
Help in Emergency
I understand that if my child requires medical attention in addition to the described above, that Agape Youth staff and/or mentors will attempt to contact me first. If I am unavailable, I authorize the Agape Youth staff/mentors to contact my child's physician. If neither I nor my child's physician is available, I authorize Agape Youth staff/mentors to order X-Rays, routine tests, and treatments; to release any records necessary for insurance purposes; and to provide or arrange records necessary for insurance purposes; and to provide or arrange transportation for my child to a nearby clinic or hospital. I will hold harmless, Agape Youth and all associated staff and volunteers from any claim of liability arising from attending the mentorship program.
Permission to Travel
I, the parent, or legal guardian of the above child, hereby give permission for my child to travel with their mentor and participate in offsite Agape Youth events. Notification will be given to parent for all off-site activities.
Permission for Photos
I, the parent, or legal guardian of the above child, hereby give permission for my child's picture and/or likeness to be used for Agape Youth promotion and advertising, including, but not limited to, brochures, newspaper or magazine articles, and the Agape Youth website.
Parent/Guardian Final Authorization
Please include your full name and date.
Note: By Checking the above permissions and signing you acknowledge that you are the parent/legal guardian of this child and that you have read and agreed with each item.
Send me a copy of my responses
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