Dr. Ernest Everett Just 2022/2023                     Mentoring Program Application
The Greater Essex Community Uplift Foundation (GECUF), in partnership with the Omega Psi Phi Fraternity, Inc., Eta Pi Chapter, Dr. Ernest Everett Just Mentoring Program, meets  on the 3rd Saturday of the month at the Omega Family Resource and Learning Center (132 S. Harrison St, East Orange, NJ, 07018) The goal of the program is to expose male youth ages 10 - 18 to life skills, college and careers.  For more Information visit www.EtaPiChapter.org, call Bro. Matt Stevens at 973.820.8999 or Email: Matt.stevens1@me.com
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Youth's Name *
Youth's Age *
Youth School  *
Youth Grade *
Parent's Name *
Parent's Email Address *
Parent's Cell Phone *
What City do you reside in? *
Please indicate if the child has any food allergies?    *
Required
 Can your child  self administer allergy treatment? *
Emergency Contact Name *
Emergency Contact Cell Phone *
I give permission to photograph or video my child for use in any promotional material  and/or to be published on social media platforms (e.g., Facebook, Twitter, etc...). *
PARENTAL PERMISSION
In consideration of you completing this form, I, the participant, intending to be legally bound do hereby waive and forever release any and all rights and claims for damages or injuries that I may have against the Greater Essex Community Uplift Foundation (GECUF), Omega Psi Phi Fraternity, Inc., Eta Pi Chapter and all of their agents assisting with the event, sponsors and their representatives, volunteers and employees for any and all injuries to me or my personal property. This release includes all injuries and/or damages suffered by me before, during or after the event. I recognize, intend and understand that this release is binding on my heirs, executors, administrators, or assignees. I know that physical activities are potentially hazardous. I should participate unless I am medically able to do so and properly trained. I assume all risks associated with participating including, but not limited to: falls, contact with other participants, the effects of weather, and waive any and all claims which I might have based on any of those and other risks typically found in physical activities. I acknowledge all such risks are known and understood by me. I agree to abide by all decisions of any official relative to my ability to safely participate. I certify as a material condition to my being permitted to participate that I am physically fit and sufficiently trained for the completion of this event and that a licensed Medical Doctor has verified my physical condition. In the event of an illness, injury or medical emergency arising during the event I hereby authorize and give my consent to the Event Director to secure from any accredited hospital, clinic and/ or physician any treatment deemed necessary for my immediate care. I agree that I will be fully responsible for payment of any and all medical services and treatment rendered to me including but not limited to medical transport, medications, treatment and hospitalization As it applies to my participation in this event, I agree to abide by the Center for Disease Control (CDC)’s recommendations for the prevention of the spread of COVID-19 and attest to having read the CDC’s guidance at: https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html. I also agree to abide by any COVID-19 distancing and other safety guidelines issued by the state, the community or by this event for my participation in this event. Further, I grant permission to all the foregoing to use my name, voice and images of myself in any photographs, motion pictures, results, publications or any other print, videographic or electronic recording of this event for legitimate purposes. By submitting this entry, I acknowledge (or a parent or adult guardian for all children under 18 years) having read and agreed to the above release and waiver.
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DONATION REQUEST
Do you plan to donate? The donation is not mandatory.
CLICK HERE TO DONATE: 
CASH APP:$EtaPiQues (Cash App)
CHECKS:  Greater Essex Community Uplift Foundation (132 S. Harrison St, East Orange, NJ 071017
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