Youth to Men 2024-2025 Information Verification
This is application for the Youth to Men program. This will, also, serve as an information verification form for returning members.

Parents must participate in 3 activities. 5 opportunities will be presented.

Mentees must participate in 85% of the activities.

The student should complete the form with a parent/guardian.
Sign in to Google to save your progress. Learn more
Email *
Are you a returning member or a new applicant? *
Mentee Last Name *
Mentee First Name *
Address *
City *
Zip Code *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Name of Current School *
Primary Email Address (Critical information will be sent to this email address: logistics, updates, critical information, reminders, etc.) *
Academic Classification for 2024/2025 *
School Activities Clubs/Interest *
Your Current Cumulative GPA *
How would you describe yourself as a student. (Use this as a current self assessment that we hope to inspire over time. Please be honest). *
Are you interested in STEM programs? If So, Which Area? Science, Technology, Engineering, Mathematics *
Required
Are you interested in Summer Leadership Institutes? *
What is your expected college major or trade? *
Church Affiliation & Position(s) Held *
Community Involvement (List Awards & Certificates) *
Mother's First Name *
Mother's Last Name *
Mother's Email *
What is your mother's email address.
Mother's Cellphone Number *
Mother's Occupation *
Father's First Name *
Father's Last Name *
Father's Email Address *
Father's Phone Number *
Father's Occupation *
Parent's commitment to the program *
Parent and student are committed to on-time transporation.
Parent and student are commited to discussing topics covered in YTM sessions.
Parent and Student are committed to volunteering to assist with the program.
Parent and student are committed to the student's participation in the program.
Parent or the student are interested in a parent's support group for a nominal charge with a professional wellness leader.
Student
Parent
Student's Current Employer *
How will the Youth To Men group help you to develop into a better individual/student? *
What contributions or talents can you offer Youth To Men? *
What importance does post secondary education or the military have for you?  (Please include the college, university, technical school, or branch of military you plan to attend/pursue).  *
Please list your career goals and fields of interest.  *
What topic(s) would you like to learn about? *
Cobb Works provides job training and other services. Would you like to learn more about the services offered? *
Applicant, what is your shirt size? *

I, do hereby release the Omicron Mu Lambda Chapter of Alpha Phi Alpha Fraternity, Inc., the Henry Arthur Callis Education Foundation (both non-profit entities organized under the laws of the State of Georgia), and their active members, officers, and directors (the “Mentors”) from any and all liability arising from mentoring, transporting, advising, supervising, teaching, instructing, and legally photographing students and mentees, including the use of photograph(s) as below-identified for presentation under any legal condition, including, but not limited to, publicity, copyrighting, illustrating, advertising, displaying, presenting, and incorporating in web content.


I understand that there shall be no payment for this release and waiver.  I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.


This Release and Waiver of Liability (the “release”) releases the Mentors and their agents from the aforementioned liability.  The Mentee desires to participate in mentoring services provided by the Mentors, specifically in the mentoring and community service programs, engaging in activities where the Mentors serve the community and mentor the youth.  Mentees understand that the scope of the relationship with the mentoring program provided by the Mentors is limited to a mentoring association and, if tasks are required for growth and development, no compensation is expected in return for services provided, if any.


Insurance: Further I understand that Mentors do not assume any responsibility for, or obligation to provide me with, financial or other assistance, including but not limited to medical, health or disability benefits or insurance of any nature in the event of my injury, illness, or damage to my property. 


Photographic Release: I grant and convey to the Mentors all rights, titles, and interests in any and all photographs, images, video, or audio recordings of me or my likeness or voice made by the Mentors in connection with services being provided to me.

 

Governing Law:  As a Mentee, I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Georgia and that this Release shall be governed by and interpreted in accordance with the laws of the State of Georgia. I agree that in the event that any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected.

 

I have understood that my authorization, to which I consented in this Release and Waiver, may never be revoked, that images will be stored in or on media that is approved by the Mentors, that said images will never be used for profit, but for charitable purposes, that said images will be kept as long as they are relevant, and that, after said images are no longer relevant, the subject images will be destroyed or archived.

Signing up for the mentoring program, I confirm my understanding and intent to enter into this Release and Waiver of Liability willing and voluntarily.


 *
Required
Student Signature and Parent Signature   *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms