Mentorship Program Mentorship Registration YOUTH INFORMATIONName* First Last Gender*FemaleMaleDate of Birth* MM DD YYYY Allergies or Medical Conditions?PARENT/GUARDIAN CONTACT INFORMATIONParent/Guardian #1 - Name* First Last Parent/Guardian #1 - Email* Parent/Guardian #1 - Cell Phone*Parent/Guardian #2 - Name First Last Parent/Guardian #2 - Email Parent/Guardian #2 - Cell PhoneHome Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone (if not a cell phone)CONSENTSPARTICIPATION: I give permission for the youth in my care noted above, to attend and participate in the Mentorship Program set forth by Northumberland Youth Unlimited. I understand that Northumberland Youth Unlimited does not provide counselling services. Due to the nature of the Mentorship Program, I give permission for the youth in my care noted above, to meet with his/her mentor one-on-one in public locations.* Yes No MEDICAL/HARM: I give permission for the person(s) in charge to seek medical assistance for the youth in my care noted above, in the event of accident or injury. Furthermore, I do not hold Northumberland Youth Unlimited or any of its subsidiary programs responsible for any harm that may occur to the youth in my care noted above, as a result of his/her wilful participation in the program.* Yes No TRANSPORTATION: If transportation is required, I give permission for the youth in my care noted above, to travel in a vehicle owned by Northumberland Youth Unlimited, or by its staff or volunteers, for the duration of the program. I understand that drivers and their vehicles are licensed and insured according to local, provincial and federal laws, insurance policies and NYU’s Policies & Procedures. Furthermore, I do not hold Northumberland Youth Unlimited responsible for any harm that may occur to the youth in my care noted above, as a result of his/her wilful participation in the transportation. Yes No PHOTO/VIDEO: I do authorize Northumberland Youth Unlimited to take, use and own, in perpetuity; names, photographs or video/audio recordings of the youth in my care noted above, understanding that these may be used for public promotional purpose. Northumberland Youth Unlimited does not sell or give away any recorded materials or mailing list information.* Yes No SIGNATURE: I acknowledge that clicking on the SUBMIT button below serves as my legal signature.PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.