BlessedGirl Mentee Application

BlessedGirl Mentee Application

Mentee Information

Parent/Guardian #1 Contact Information

Parent/Guardian #2 Contact Information

Emergency Contact Information

Member Medical Information

IN CASE OF EMERGENCY, I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO CONTACT ME. IN THE EVENT THAT I CANNOT BE REACHED, I HEREBY GIVE PERMISSION TO THE HOSPITAL AND ATTENDING PHYSICIAN SELECTED BY BLESSED GIRLS TO TAKE ANY NECESSARY ACTION, INCLUDING SURGERY, ANESTHESIA, OR INJECTIONS, THAT IS IN THE BEST INTEREST OF MY CHILD.

MEDICAL DECLARATION STATEMENT FOR SCHOOL-AGED CHILD CARE

As a parent/guardian of the above participating child, I certify the he/she is in good physical health, has no special needs, and may participating in all of the activities of the Blessed Girl Program, except as noted above.