JHOSI YIP Youth Innovators/Mentoring and Leadership Program
Meeting Location

2165 West Park Court Suite F

Stone Mountain, GA 30087
http://www.jaredsheartofsuccess.com/events

Participant Information (Youth/Teen)

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Cell Phone Number *

Gender

Birth Date +

Grade

Elementary/Middle/High School *

Elementary School

Middle School

High School

Name of School *

Parents/Guardians Info:

Relationship to Participant: *

First Name Mother/Guardian *

Last Name Mother/Guardian *

Address 1 *

Address 2

City *

State *

Zip *

Phone

Alternate Phone

Mother Occupation/Employer *

Email Address *

Father's First Name *

Father's Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Father's Occupation/Employer *

Email Address *

Emergency Contact:

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Emergency/Medical Info:

Medical Concerns/Allergies: *

Medications: *

Special Diet or Diet restrictions: *

Does your child have any physical problems or limitations that we need to be made aware? Please state: *

Does your child have any behavioral problems or issues we need to be aware of? *

Does your child have any emotional issues, or have experienced any traumatic events that we need to be made aware of? *

Questionnaire for Student participant (YIP) Youth Innovators Program:

The questions are designed to help us get to know who you are, where your passion comes from, and what you hope to accomplish. In one sentence or phrase, tell us what community, cause area, or social issue you want to impact with your project. *

Briefly state what motivates you to make a difference in the world around you? *

Briefly share any additional experiences you have had that is relevant to your passion area, examples: websites, blogs,social media, videos, etc. *

Questionnaire for Parents regarding youth/teen participant: Mentoring and Leadership session

Briefly state your expectations of JHOSI *

What is the main reason you have enrolled your youth or teen into the program here? *

What do you hope your youth or teen will gain through his/or her participation with JHOSI *

Other? Please state: *

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? *

Bullying Prevention awareness

Health & Wellness

Financial Planning/Money Management/Finsncial Literacy

Teen Dating and Domestic violence

Community Outreach/volunteering

Prevention Underage Drinking

College and Career readiness

If there is another area not listed you would like please state: *

JHOSI needs your assistance please specify ways you are willing to assist us? *

If there is another please specify: *

List additional comments if desired *

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.

The first session of the program covers the (YIP) Youth Innovators Program August-December 2019.

The second session of the program covers Mentoring and Leadership Develpoment January-May 2020.

JHOSI youth organization does teach prevention awareness on the dangers of drugs, and alcohol: underage drinking, teen dating violence, bullying prevention, self-esteem, peer pressure, and any type of violence or victimization through our SAVE program.

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 23, 2019 @ 5:30 PM. I fully understand the meetings will be monthly 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 9:00 AM unless otherwise noted. I also understand the registration fee is $50.00 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. *

Yes I agree

https://www.paypal.me/jaredsheartofsuccess

Parent/Guardian Signature *