School Based Mentoring - Amachi Pittsburgh

Youth Name*

First Last

Youth Preferred Name or Nickname

First

Birth Date*

Youth Gender*

Youth Pronouns, please select all that apply.*

With which race/ethnicity does the youth identify?*

Name of Current School*

Name of School District*

Current Grade Level*

Anticipated Graduation Year*

Caregiver Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Caregiver Phone*

Caregiver Email*

Consent*

I understand

I fully understand that the mentoring program will be completed by employees of Amachi Pittsburgh, who will be supervised by an identified employee of the school district. The mentors will spend around 30-45 minutes weekly with my child, on-site, in a group setting in School. The mentors will not take or meet my child beyond the school premises, and I understand that a staff member will be present for each session. My address will only be used to offer additional resources and programs to my child/family.

*

I give Permission
I do not give permission for my child to participate in the Amachi Mentoring Program.

I give permission for my child, to receive weekly mentoring services at school listed through the Amachi Mentoring Program. I understand the nature and rules of the school’s mentoring program and reserve the right to withdraw my child from the program at any time.

*

I give permission for my child’s photo to be taken and potentially shared externally.
I do not give permission for my child’s photo to be taken and potentially shared externally.

I also understand that pictures or videos may be taken depending during activities in the program that Amachi Pittsburgh and/or third party services may use for promotional and reporting purposes.

Parent/Caregiver Signature*

Date*

I am interested in learning more about Amachi’s other programs and services. If so, an Amachi staff member will be in touch shortly.

Amachi School Based Mentoring Program