2018- 2019 Registration Mentoring & Leadership Program

JHOSI Heart to Succeed Mentoring & Leadership Program
Meeting Location
2165 West Park Court Suite F
Stone Mountain, GA 30087

Participant Information (Youth/Teen)

Elementary/Middle/High School *

Parents/Guardians Info:

Relationship to Participant: *

Emergency Contact:

Emergency/Medical Info:

Questionnaire for Parents regarding youth/teen participant:

What do you hope your youth or teen will gain through his/or her participation with JHOSI *
JHOSI offer workshops & resources to our parents would you be interest in joining us, if so what topics would best interest you and would you assist with our community outreach? *
JHOSI needs your assistance please specify ways you are willing to assist us? *

Parental Agreement Authorization:

Please read and check below to give permission for participation into the program.
I give permission for my child to participate in (JHOSI) Jared's Heart Of Success Mentoring and Leadership program. I understand that the organization does teach prevention awareness in drugs, and alcohol ~ underage drinking, teen dating violence, and bullying prevention.
I also understand JHOSI serves all individuals and does not discriminate race, sex, or age.

I have been made aware that throughout the program Christian Biblical principles are mentioned and discussed within the group mentoring program sessions.

I have been made aware that JHOSI screen their volunteers and each will meet JHOSI criteria and background checks to ensure the safety of each individual. I understand that if I have concerns I'm encouraged to address them with the program director.
I do understand that I can withdraw my child at any time from the program. I have been made aware of the program tentative meeting dates, participation and involvement as a member within the program.
I understand that I must attend the parent information session August 25, 2018 @ 11:00 AM. I fully understand the meetings will be bi-weekly during the school calendar year unless otherwise noted. I have explained the rules to my child/children and I agree that JHOSI will not be responsible for any accident to my child/children while participating in JHOSI activities on or off site.
In the event of an emergency and I can't be reached I give permission for my child/children to be treated by a physician and or hospital. I give permission to photographs/video and other forms of media in which my child/children may appear during activities with JHOSI for its purpose.
I understand that I'm responsible for transporting my child/children to and from program activities, and at the start and conclusion of the program, I understand that my child/children may participate in a pre and post survey given during JHOSI programs. I do understand that information is gathered will be kept in confidence and used for evaluation purposes only.
I do understand that the program session will start timely at 11:00 AM unless otherwise noted. I also understand the registration fee is $20.00 per child. The registration fee will cover materials and their t-shirt which is required to be wore during field trips, events off-site: (summits, conferences, community outreach events) etc.
Check below if in agreement to all terms stated and outlined by JHOSI and next click on the secure website to pay your registration fee. *
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