Please support us by linking your Kroger Plus card to Mountain Mentors. When you shop Kroger donates a percent of your purchases to us. This in no way affects the discount you receive or the cost of your purchase. Basically its a win-win. All you have to do is enroll your card through an email address. Click here for instructions.
Student / Parent Registration
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Mountain Mentors
Student Registration
Name of Student __________________________________________________________________________ ___________________________________________________________________________ Address Phones: Home (H); Cell (C) Mother or Guardian 1.__________________________________Employer _____________________________ Address__________________________________________Phones: (H)
Street City, State Zip
(W)
(C)
Email ______________________________________________________________________ Father or Guardian 2.__________________________________Employer ___________________________ Address _________________________________________Phones: (H)
Street City, State Zip
(W)
(C)
Indicate parental custody of student if appropriate________________________________________________ Student’s School_____________________________ Grade_____________ Age ____Birthdate____________ In case of an emergency, contact: Name_______________________________ Address_____________________________
Street
or
Name______________________________________ Address____________________________________
Street
______________________________
City Phone(s) State Zip
__________________________________________
City Phone(s) State Zip
______________________________ Relationship to student_________________
__________________________________________ Relationship to student________________________
Having agreed to participate in the Mountain Mentors program, we understand and agree to the following:
Student Obligations • Participate in 75% or more in all Mountain Mentor activities to be eligible for the hiking/wilderness expedition for the period of one year • Required attendance and participation at monthly Mountain Mentor meetings • Weekly contacts with assigned mentor. Mentors will initiate phone calls; students are asked to return calls to their mentors that they miss • Enrollment to the Erie Shores Council Empowered Leadership program • I will be expected to meet with my mentor at least twice monthly in addition to the team monthly activities. • Participation in the hiking/wilderness week to New Hampshire and the activities associated with it Parent/Guardian Obligation • Notify the students mentor of changes to address, phone number or school enrollment of student • Support your child in their attendance at Mountain Mentor activities • Volunteer for two hours or more to support the Mountain Mentor program Program Obligations • Provide a caring and committed volunteer mentor to serve as a mentor for the program year • Provide transportation for student to Mountain Mentor activities • Ensure a safe environment at all times during Mountain Mentor activities • Provide advocacy for the student in areas of court, school, and family
We understand that this registration indicates our willingness to be for enrollment into the Mountain Mentors program. Name of student (Print) ___________________________ Name of Parent/Guardian (Print)_____________________________________
Student Signature __________________________
Parent/Guardian Signature _________________________Date________
Mountain Mentors
Student Registration
Name of Student __________________________________________________________________________ ___________________________________________________________________________ Address Phones: Home (H); Cell (C) Mother or Guardian 1.__________________________________Employer _____________________________ Address__________________________________________Phones: (H)
Street City, State Zip
(W)
(C)
Email ______________________________________________________________________ Father or Guardian 2.__________________________________Employer ___________________________ Address _________________________________________Phones: (H)
Street City, State Zip
(W)
(C)
Indicate parental custody of student if appropriate________________________________________________ Student’s School_____________________________ Grade_____________ Age ____Birthdate____________ In case of an emergency, contact: Name_______________________________ Address_____________________________
Street
or
Name______________________________________ Address____________________________________
Street
______________________________
City Phone(s) State Zip
__________________________________________
City Phone(s) State Zip
______________________________ Relationship to student_________________
__________________________________________ Relationship to student________________________
Having agreed to participate in the Mountain Mentors program, we understand and agree to the following:
Student Obligations • Participate in 75% or more in all Mountain Mentor activities to be eligible for the hiking/wilderness expedition for the period of one year • Required attendance and participation at monthly Mountain Mentor meetings • Weekly contacts with assigned mentor. Mentors will initiate phone calls; students are asked to return calls to their mentors that they miss • Enrollment to the Erie Shores Council Empowered Leadership program • I will be expected to meet with my mentor at least twice monthly in addition to the team monthly activities. • Participation in the hiking/wilderness week to New Hampshire and the activities associated with it Parent/Guardian Obligation • Notify the students mentor of changes to address, phone number or school enrollment of student • Support your child in their attendance at Mountain Mentor activities • Volunteer for two hours or more to support the Mountain Mentor program Program Obligations • Provide a caring and committed volunteer mentor to serve as a mentor for the program year • Provide transportation for student to Mountain Mentor activities • Ensure a safe environment at all times during Mountain Mentor activities • Provide advocacy for the student in areas of court, school, and family
We understand that this registration indicates our willingness to be for enrollment into the Mountain Mentors program. Name of student (Print) ___________________________ Name of Parent/Guardian (Print)_____________________________________
Student Signature __________________________
Parent/Guardian Signature _________________________Date________
This document has been released into the public domain.
