Student Application


Name of Student *
Name of Student
Mountain Mentors is intended for teens, ages 13 - 17. Exceptions are deemed appropriate by the program director.
Student's Permanent Address *
Student's Permanent Address
Phone
Phone
Parent or Guardian 1 *
Parent or Guardian 1
Address *
Address
Cell Phone *
Cell Phone
Work Phone *
Work Phone
Parent or Guardian 2
Parent or Guardian 2
Address
Address
Cell Phone
Cell Phone
Work Phone
Work Phone
Student special circumstances, questions, concerns... etc.
I____________________________for myself, my child, and my/our heirs, executors, administrators and assigns, do hereby waive, release and forever discharge and agree to indemnify and defend Mountain Mentors, its members, officers, administrators, employees, volunteers, servants, and agents from and against all claims, demands, or causes of action by any person or entity, for any theft, loss, cost, injury, death, or damages whatsoever arising from or claimed to arise from or in any way connected with the named child’s participation in the Mountain Mentors program and activities. By typing name below you are accepting and agreeing to the terms above.