Dream Keepers Mentoring Program
Registration: To be filled out by the parent/guardian of youth participating in Mentoring Program
Meetings will be held the first week of every month except on holidays from 5:30-pm -7:00pm 
Running Rebels Community Center 225 W. Capitol Dr. Milwaukee WI 53212
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Email *
Child's Full Name *
Child's DOB *
MM
/
DD
/
YYYY
Child's Grade   *
School Attending *
Special Interest or Hobbies *
What do you want your child to gain from our mentoring program? *
Street Address *
City, State, Zip *
Parent / Guardian Name *
Parent / Guardian Phone Number *
Emergency Contact 1 Name *
Emergency  Contact 1 Phone Number *
Emergency Contact 1 Relationship to Child *
Emergency Contact 2 Name *
Emergency Contact 2 Phone Number *
Emergency Contact 2 Relationship to Child *
Medications (including Inhalers):  If your child must take medication while at our program, please note here. All medications must be in their original containers and be appropriately labeled. Please do not give your child's medication to them to bring to mentor sessions; medications must be received and held by the Mentor or with the Program director. *
Required
If yes, please specify

WAIVER OF LIABILITY

Consent for Participation:By typing my full name below, as the parent/guardian of the child listed above, I permit my child to participate in the Dream Keepers Mentoring Program, including group activities.Acknowledgment of Risks:I understand that injuries may occur during the program, and I'm responsible for any associated medical costs.Responsibility for Personal Property:I accept responsibility for my child's personal property during the program, relieving Dream Keepers, Inc. of any liability.Emergency Care Authorization:In case of injury or sickness, I authorize immediate care by any healthcare professional designated by Dream Keepers, Inc.Waiver and Release of Claims:I release Dream Keepers, Inc. from any claims, except those caused by gross negligence or willful misconduct.Photo/Video Consent:I grant permission for Dream Keepers, Inc. to use my child's photos or videos for promotional purposes.Transportation Consent:I acknowledge that my child may be transported by Dream Keepers, Inc., and I release them from liability for any incidents during transportation.

This waiver indicates my understanding and acceptance of the risks, and I assume responsibility for associated costs, releasing Dream Keepers, Inc. from specified liabilities.

Parent/Guardian Consent:Parent/Guardian Full Name: [Type Full Name]

Date: [Date]

 *

INDIVIDUAL CONTRACT

Contract Terms: By entering my name below as the parent/guardian of the child mentioned above, I agree to the following terms with Dream Keepers, Inc. for my child's participation in the mentoring program and summer camp.Risk and Responsibility:I understand there are risks involved, like injuries or illness. I've chosen an appropriate level for my child based on their abilities and health.Waiver and Release:To let my child join, I promise not to hold Dream Keepers, Inc., its team, or anyone involved responsible for accidents or costs due to negligence of stolen, lost or damaged items. Photo Use:I'm cool with Dream Keepers, Inc. using my child's photos for program-related publicity.Behavioral Expectations:My child needs to follow the rules, and if their behavior affects others negatively, they might be asked to leave the program.Transportation Consent:I'm giving permission for Dream Keepers, Inc. to transport my child. I understand they won't be responsible for any injuries or incidents during transportation.Refund Policy:I know there are no refunds once my child is enrolled in the program.Agreement:I have read this entire Informed Consent Agreement. I fully understand it and I agree to be legally bound by it.

Parent/Guardian Consent:Parent/Guardian Full Name: [Type Full Name]Date: [Date]

 *
PLEASE NOTE: All parents are required to attend our Parent Orientation session.
Check below to confirm if you will be available to attend. 
Parent orientation is an hour long it can be completed in person or virtually. Please select below
 *
Please indicate the date and time you'd be available to complete parent orientation. *
How did you hear about our programs? If someone referred you please list their name. *
A copy of your responses will be emailed to the address you provided.
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