We are only accepting male mentees ages 13-17 at this time.
The undersigned does hereby give permission for my child
to attend and participate in any 100 Black Men of Jacksonville, Inc. (J100) activities, events, and program meetings during the period of
In consideration of J100 allowing the Participant to participate in children/youth program meetings, activities, events, and trips I, the undersigned, do hereby release, forever discharge and agree to hold harmless executive leadership, directors, employees, members and volunteers (collectively herein the “J100” from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities. I the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in children/youth activities, including trips away from the J100 facilities. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify the J100 for any liability sustained by the J100 as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.
I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.
Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.
The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by the J100. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.
List all medications the youth will take during any youth trips, retreats, or events. This includes any prescription, non-prescription medications, herbal supplements and vitamins. Any participant under the age of 18 is required to give ALL MEDICATIONS to the adult youth leader in their original containers with complete dispensing instructions before the start of the event. Youth are not permitted to carry any prescription or non-prescription medication and will be sent home at the parent/guardian’s expense if they do.
Do you give permission for your child/youth to be given over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth event?
Please answer in detail if applicable or write N/A.
The following rules and guidelines are basic expectations for J100 youth and mentee participants:
Non-Negotiable Rules
Any participant failing to abide by these rules will be sent home immediately at personal/family expense.
Youth Participant’s Statement: By signing this form, I pledge to respect others during J100 activities by following the rules and guidelines printed above. I understand that I cannot participate in the activity unless this completed form is on file.
Parent/Guardian’s Statement: By signing this form, I agree to support the rules and Expectations of the J100 printed above, and will accept responsibility for the payment of my child’s return transportation should s/he break one of the non-negotiable rules.
I agree that the J100 may photograph and record my child/dependent’s likeness and activities (Images)[1] during J100 activities. I grant the following rights to the J100: permission to use and re-use, publish and re-publish, and modify or alter the Image(s) taken during the shoot. Use of the Images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the church website and on the Internet, and worldwide in perpetuity for the purposes stated above.
I waive my right to inspect or approve any editorial text or copy that is used in connection with the Images and release and discharge the J100 from any and all claims arising out of use of the Images for the purposes described above, including any claims for libel, invasion of privacy, or other tortuous act.
I have read the foregoing. I fully understand its contents, understand that this agreement does not expire, and confirm my agreement by signing below. I am over the age of 21 and have legal capacity to sign the release.
[1] Images means all photographs, film, or other recordings taken of them as part of the Shoot.
