MENTEE APPLICATION

Application Questions:

Please answer all of the following questions as completely as possible.

Medical History

Please read this carefully before signing:

100 Black Men of Jackson, Inc. appreciates you and your child's interest in his becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their child to participate in the 100 Black Men of Jackson, Inc. Mentoring Program.

After receiving the completed application form, we will evaluate the information and send a letter informing you if your child has been accepted into the program. The information you supply in this packet will be used to match your child with an appropriate mentor. Therefore, the mentoring staff may, at times, need to access and share this information with prospective mentors and other parties when it is in the best interest of the match. However, we do not reveal names until there is an initial interest from the mentee, parent/guardian, and mentor based first upon anonymous information provided about each other.

I give my information consent and permission for my child to participate in the 100 Black Men of Jackson, Inc. Mentoring Program and its related activities.

I agree to have my child follow all mentoring program guidelines and understand that any violation on my child's part may result in suspension and/or termination of the mentoring relationship

I hereby acknowledge that my child will be transported by his mentor and/or 100 Black Men of Jackson, Inc. staff or representative while participating in the 100 Black Men of Jackson, Inc. Mentoring Program, and that such transportation is voluntary and at his own risk

I release the 100 Black Men of Jackson, Inc. of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his participation in the program, including but not limited to transportation, and hold harmless any 100 Black Men of Jackson, Inc. mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

I agree to allow 100 Black Men of Jackson, Inc. to use any photographic image of my child taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.

***Initials and Signatures of Approval are required for all items listed under Consents; however, in the best interest of the child, Mentors, and staff, certain activities/services will not occur in-person unless consistent with guidelines issued by the Centers for Disease Control (CDC), Mississippi Department of Health (MDH), and 100 Black Men of Jackson, Inc.

Contact and Information Release

(To Be Completed by the Parent/Guardian)

I hereby grant permission for the 100 Black Men of Jackson, Inc. to make contact with my child and conduct a personal interview for the purposes of applying to be a mentee. The 100 Black Men of Jackson, Inc. may also make contact with my child on school premises for the purposes of screening and interviewing as well as ongoing support of his participation in the mentoring program.

I authorize the 100 Black Men of Jackson, Inc. to obtain any needed information regarding my child from his school's staff, including academic and behavioral records and conservations with teachers, counselors, and other administrative staff.

Further, I understand that basic information about my child will be anonymously (without names) shared with a prospective mentor(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my identity and my child's identity and other relevant information will be shared with the mentor to the extent it aids in facilitating a successful match.

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization, COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

100 Black Men of Jackson, Inc. ("The 100") has put in place preventive measures to reduce the spread of COVID-19, contact with mentees will be mostly through virtual means. During the pandemic, The 100 will limit physical contact; however, The 100 cannot guarantee that you or your child(ren) will not become infected with COVID-19 during in-person meetings.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending events sponsored by The 100 and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 during events sponsored by The 100 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees of The 100, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)'s attendance at events sponsored by The 100 or participation in The 100 programming ("Claims"). On my behlaf, and on behalf of my child(ren), I hereby release, covenant not to sue, discharge, and hold harmless 100 Black Men of Jackson, Inc. its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of The 100, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any program of The 100.

By Signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.