Apply — Uncomfortable Changes Mentorship

1 · Parent Info

2 · About My Child

3 · Review & Submit

✅

Application Received!

Thank you for applying to Uncomfortable Changes Mentorship Program. Our coordinator will review your application and be in touch at the email you provided within a few business days.

Next step: Watch your inbox for an acceptance email with payment instructions to secure your spot.

Parent / Guardian Information

First Name *

Last Name *

Email Address * This is where acceptance & payment info will be sent.

Phone Number *

Relationship to Child *

Emergency Contact (if different)

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

I am enrolling more than one child — I would like the 20% sibling discount on additional enrollments.

Child Information

Child's First Name *

Child's Last Name *

Child's Age *

Current Grade *

Child's Gender

Child's Race / Ethnicity

School Your Child Attends *

Does Your Child Attend Church? *

If yes, what church does your child attend?

About My Child

What are your child's hobbies and interests? *

How would you describe your child's personality? *

Why are you interested in this mentorship program for your child? *

What areas of growth would you like to see in your child? *

What does your child's current relationship with faith or church look like?

Favorite Foods & Snacks

Favorite Drinks

Does your child have any food allergies? *

Does your child have any medical allergies? *

If yes, please describe all allergies in detail This information is confidential and shared only with program coordinators and mentors for your child's safety.

Is there anything our mentors should know to support your child well? This information is confidential and only seen by program coordinators.

How did you hear about Uncomfortable Changes?

Membership Plan

If accepted, which payment plan would you prefer? *

Monthly — $20/month 6 Months — $60 one payment ($10/mo) BEST VALUE Annual — $100/year ($8.33/mo)

Waivers, Agreements & Consent

Please read each section carefully before checking the boxes below. All items marked with * are required to complete enrollment. By signing and submitting this form, the parent or legal guardian agrees to all terms stated herein on behalf of their minor child.

⚑ Program Participation

📋 Participation Agreement

I, the undersigned parent or legal guardian, give full permission for my child to participate in all activities associated with the Uncomfortable Changes Mentorship Program, including but not limited to group sessions, game nights, faith-based discussions, team activities, and any other structured programming offered during the program period. I confirm that all information provided in this application is truthful and accurate to the best of my knowledge.

✝ Mandatory Church Attendance

⛪ Church Attendance Requirement — MANDATORY

As a condition of enrollment and continued participation in the Uncomfortable Changes Mentorship Program, I understand and agree that my child is required to attend church a minimum of two (2) times per month for the duration of the program. This is a non-negotiable requirement of the program and is rooted in our commitment to grounding every participant in consistent Christian community and worship. Failure to meet this attendance requirement without prior notice to the program coordinator may result in my child's removal from the program without refund.

⚠ Injury & Liability Waiver

🛡️ Release of Liability — Accidental Injury

I understand and acknowledge that participation in game nights and physical activities involves inherent risks of accidental injury. In consideration of my child's participation in the Uncomfortable Changes Mentorship Program, I, on behalf of myself, my child, and our heirs, executors, and assigns, hereby voluntarily release, waive, discharge, and covenant not to sue Uncomfortable Changes Mentorship Program, its organizers, coordinators, volunteers, mentors, partnering churches, and any affiliated ministry or organization (collectively "the Program") from any and all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, or injury, including death, that may be sustained by my child while participating in any program activity, whether caused by the negligence of the Program or otherwise, to the fullest extent permitted by law.

🏛️ Indemnification & Hold Harmless Agreement

I agree to indemnify and hold harmless the Uncomfortable Changes Mentorship Program, its organizers, partnering churches, mentors, and volunteers against any and all claims, suits, losses, damages, costs, and expenses (including reasonable attorney's fees) arising from my child's participation in program activities. This includes claims arising from accidental injury, property damage, or any incident occurring on or off the premises during sanctioned program events. I further acknowledge that this release applies to any claims based on the Program's alleged negligence, and that I have had the opportunity to review this agreement prior to signing.

🌿 Allergy & Medical Condition Waiver

⚕️ Allergy & Medical Condition Release

I understand that food, snacks, and beverages may be present or served during program sessions. I accept full responsibility for notifying the program coordinator of any and all food allergies, dietary restrictions, or medical conditions that could result in an allergic or adverse reaction for my child, as disclosed in the application. I agree that the Uncomfortable Changes Mentorship Program, its staff, mentors, and volunteers shall not be held liable for any allergic reaction, adverse medical event, or injury resulting from my child's exposure to food, materials, or environmental conditions during program activities, provided that reasonable care has been taken with the allergy information I have disclosed. It is my responsibility to ensure this form reflects complete and accurate allergy information.

🚑 Medical Emergency Authorization

🚨 Consent to Call Emergency Medical Services

In the event of a medical emergency involving my child during any Uncomfortable Changes Mentorship Program activity, I hereby authorize program staff, mentors, or volunteers to immediately contact emergency medical services (911) on behalf of my child. I understand that program staff will attempt to contact me as the parent or guardian as quickly as possible, but authorize them to call for emergency assistance without delay if they believe my child's health or safety is at risk.

🏥 Consent for Medical Transport & Treatment

I authorize emergency medical personnel, paramedics, and medical professionals responding to an emergency involving my child to provide emergency medical treatment and, if necessary, transport my child to the nearest appropriate medical facility or hospital. I understand that program staff will not prevent or delay emergency medical transport if emergency responders determine it is necessary. I accept financial responsibility for any medical treatment or transport costs incurred on behalf of my child. The Uncomfortable Changes Mentorship Program shall not be held liable for any medical costs, treatment decisions, or outcomes resulting from emergency medical care provided under this authorization.

💊 Medical Treatment Authorization

In the event that I cannot be reached in a timely manner during a medical emergency, I authorize program staff to consent to emergency medical treatment on my child's behalf as recommended by qualified medical personnel. I understand this authorization applies only to emergency situations and does not extend to elective or non-urgent medical decisions. I agree to hold harmless the Program, its staff, mentors, and volunteers for any medical decisions made in good faith during an emergency in which I could not be reached.

📸 Media & Communications

📷 Photo & Video Release (Optional)

I grant permission for the Uncomfortable Changes Mentorship Program to photograph and/or record my child during program activities. These images and recordings may be used for ministry purposes including social media, promotional materials, and program documentation. No images will be sold or shared with third parties for commercial purposes. This release is voluntary — declining does not affect my child's enrollment.

🛡️ Safety & Policies

📄 Safety Policy Acknowledgment — MANDATORY

I have reviewed the Uncomfortable Changes Safety & Policies page and agree to the program's Safety Policy, Mentor Background Check Disclosure, Code of Conduct, Photo & Media Policy, and Parent/Guardian Agreement Summary as stated therein.

✅ Acknowledgments — All Required

I give permission for my child to participate in all Uncomfortable Changes Mentorship Program activities including game nights, group sessions, and faith-based programming. * I understand and agree that mandatory church attendance (minimum 2 times per month) is a required condition of enrollment, and that failure to comply may result in removal from the program without refund. * I have read and agree to the Release of Liability and Indemnification Agreement. I understand my child participates in physical activities at their own risk and I waive my right to hold the Program liable for accidental injury to the fullest extent permitted by law. * I have disclosed all known food and medical allergies in this application and I accept responsibility for ensuring this information is accurate and complete. I release the Program from liability for allergic reactions arising from undisclosed or unknown allergies. * I authorize program staff to call 911 and emergency medical services on behalf of my child in the event of a medical emergency during any program activity. * I authorize emergency medical personnel to provide emergency treatment and transport my child to a medical facility if necessary. I accept financial responsibility for any resulting medical costs. * I give optional permission for my child to be photographed or recorded during program activities for ministry and promotional use. I have reviewed the Safety & Policies page and agree to all policies and terms stated therein. * I agree to receive program communications (acceptance, payment link, updates) at the email address I provided. * I confirm that all information in this application is truthful and accurate. I understand enrollment is limited to 50 participants and is confirmed only upon payment receipt after acceptance. *

Parent / Guardian Full Legal Name (Electronic Signature) *

By typing your full name above, you are electronically signing all waivers and agreements on this page on behalf of yourself and your minor child. This electronic signature carries the same legal weight as a handwritten signature.

Today's Date *

City & State *

Additional Notes for the Coordinator

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