Mentee Application FormMeet Avery - Lymphoma warrior Mentee Application Form Meet Avery - Lymphoma warrior Online Mentee Application 1Contact information2About your child3Parental consent Contact infoChild's name* First Last Birthdate* MM slash DD slash YYYY Type of Cancer* Parent/Guardian name* First Last Phone*Email EMERGENCY CONTACT: Name* First Last EMERGENCY CONTACT: Phone* About your childIs your child able to connect with their mentor at least once a week?* Y N What are the best times and days for your child’s mentor to contact them?* Week days Weekends Morning Afternoon Evening What would be the best way for your child and mentor to communicate?* Phone Skype Email Other If you selected other, explain best way to communicate*Mark all activities your child is interested in: Animals Biking Board games Boating Camping Church Cooking Fishing Gardening Golf Hiking Library Movies Music Parks Reading Sewing Shopping Sports Swimming Other special interests? Any other information that will help matching your child with a mentor. Parental consentThe "undersigned" means parent or guardian of the child. The undersigned acknowledges and agrees to: I acknowledge that I am the parent/guardian of the child applying for the mentorship program. I acknowledge that I have read and understood the contents of this form and I give my informed consent and permission for my child to participate in the NCCS mentoring program and its related activities. I understand that this program is voluntary. I understand that basic information about my child will be anonymously shared with prospective mentors to aid in determining a suitable match. Once a mentor/mentee match is determined, mine and my child’s identity, and other relevant information will be shared with the mentor to the extent that it aids in facilitating a successful match. I agree to have my child follow all mentoring guidelines and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship. As the undersigned, I have read this release before signing below and I fully understand the contents, meaning and impact of the release.Parent/Guardian Name* Date* MM slash DD slash YYYY By clicking “submit,” I provide my signature expressly consenting to contact from NCCS or its subsidiaries, affiliates, or agents at the number I provided regarding products or services via live, automated or prerecorded telephone call, text message, or email. I understand that my telephone company may impose charges on me for these contacts, and I am not required to enter into this agreement as a condition of purchasing property, goods, or services. I understand that I can revoke this consent at any time. 10853
