Forms & Resources Enrollment Personal Information Form Personal Information FormChild's Name *Age *Weight (lbs) Child's Shirt Size Date of Birth *School *Phone Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryAllergies & Medical Conditions *Type "None" if not applicableFamily Doctor Name, Address, PhoneParent/Guardian *Phone Alternate Number Best time to contact Parent Email *Additional Email Emergency Contact Name, Address, PhoneNotes VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: Strengths & Weaknesses Assessment Strengths & Weaknesses AssessmentCourses Leadership Skills, Anger Management, Conflict resolution, Art, History, Effective Public Speaking, Health & Wellness, Etiquette, Financial Literacy, Job Readiness, ProfessionalismYour Name Child's Name What are your child’s strengths you would like to build upon associated with the courses listed? What are your child’s weaknesses associated with the courses listed? Does your child have behavioral challenges, learning disability, I.E.P, in counseling or therapy? If yes, give details What is your expectation of the Leadership academy? Please have your child choose a career and field of study. VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: Enrollment Consent Form Enrollment Consent FormName of Participant *Beginning Date End Date Your youth leader has been invited to take part in I AM MENtality’s Leadership Academy. Participants will be involved individual skills development training, group discussions, group activities, as well as periodic off site cultural enrichment activities. PERMISSION TO PARTICIPATE I, the undersigned (Parent), consent for my child to participate in the I AM Mentality Mentoring Program . I agree to hold harmless I AM MENtality against any liability, loss, or expense incurred or suffered in consequence of any action or actions, suit or suits, in law or equity, which may be brought by any person or persons in connection with, or with reference to, the administration, planning, preparation, development, conduct, and execution of the Leadership Academy. I understand that my child will participate in I AM Mentality’s Leadership Academy Program during the time indicated above. With advanced notice, these times and dates may be adjusted. Release of Information/Records: I, the undersigned, consent to I AM MENtality and any third party or independent evaluation team to have my child participate in program surveys and collect data about my child over the course of the . I understand that Leadership Academy. My child will complete a confidential survey about his attitudes and opinions as part of an evaluation. I understand the information obtained will be statistically analyzed and that my child's name will be withheld for confidentiality purposes. I understand that this information, in addition to the survey, will be part of a larger evaluation and only the evaluation team and I AM MENtality program staff will have access to this confidential information. I understand that while there are limited risks inherent with the activities that are included in the Program I willingly assume these risks in order to allow my child to participate. If I cannot be reached in the event of an emergency, I give permission for any care or treatment by a physician, surgeon, hospital, nurse, and doctor’s assistants, or medical care facility that may be required. Transportation: I fully understand that periodically my child may be invited to participate in field trips and off site events as part of the program. Program staff may transport my child in a charter or leased vehicle to and from various activities and hereby release and hold harmless I AM MENtality against any liability, loss, or expense incurred or suffered in consequence of any action or actions, suit or suits, in law or equity, which may be brought by any person or persons in connection with, or with reference to, the administration, planning, preparation, development, conduct, and execution of the Leadership Academy program. Photograph: I fully understand that my child's writings, photos, and videos may be displayed on the I AM MENtality’s blog, website, and other social media outlets. I understand that my child might be in contact with the press at I AM MENtality’s special events and open houses. Also, it may be necessary for program staff to photograph or videotape program youth to advertise the Program or for other purposes. I give permission for program staff to photograph or video tape my child.Name of Parent Today's Date By typing my name and checking the box I agree to the following: I HAVE READ AND FULLY UNDERSTAND THE ABOVE INFORMATION AND AGREE TO ASSUME ALL RISKS.I Agree VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: Who I Am Who I AmFull Name *Age *Mother's Full Name *Father's Full Name *Where do I Live (Community): *School *Career Choice/Field of Study: *Leadership Skills, Anger Management, Conflict resolution, Art, History, Effective Public Speaking, Health & Wellness, Etiquette, Financial Literacy, Job Readiness, Professionalism VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: Counseling Forms Counseling Intake Form I AM MENtality Counseling/ Mentoring Form Purpose: I AM MENtality provides counseling, mentoring, and coaching for male youth ages 5 to 16 years of age.Client's Name *Birthdate of Client *Client SSN *Parent(s) Name *Parent Email *Additional E-mail Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryPhone Number *MA# Reason for Referral VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: Participant Resources Leadership Quotes Principle Living Vocabulary List Book List Wealth Principles Note Writing MENtality Student Success Model Morning Acclimations Movie List Who I am
