FIERCE TEEN APPLICATION

FIERCE TEEN APPLICATION
- Full Name:*
  
  First NameMiddle NameLast Name
- Nickname
- Gender:*
  
  MaleFemaleOther
- Is your teen:
  
  NEW- has never completed mentoring full sessionRETURNING
- Address:*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Phone Number*
  
  Area CodePhone Number
- Race
- DOB:*
  
  MonthDayYear
- Age:*
- Current Grade:*
- School/Education Program Teen attends?*
- Does the Teen participate in any school activities?:
  
  BasketballFootballBaseballSoftballTrackBandStudent CouncilROTCOther
- Please give other activity details:
- Does the Teen have a job?:
  
  YesNo
- Who Does Teen Currently Reside With?*
  
  Mother OnlyFather OnlyFather & MotherFamily MemberFoster/Group HomeStep-Mother/Step-FatherOther
- Who is completing this Application?*
  
  MotherFatherLegal GuardianFamily MemberStep-Mother/Step-FatherOther
- Full Name*
  
  First NameLast Name
- Email*
  
  Confirmation Emailexample@example.com
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Home Number*
  
  Area CodePhone Number
- Work Number (Emergency Only)
  
  Area CodePhone Number
- Occupation:
- Emergency Contact:*
- Emergency Contact Relationship to Teen:*
- Other 'Please Specifiy'
- Emergency Contact Phone Number*
  
  Area CodePhone Number
- Does the teen have Transportation to Mentoring?*
  
  YesNoWill ride Public TransportationWill Ride with Friend/Family Member
- Does the Teen have any Food Allergies:*
  
  YesNo
- If Selected Yes above, please explain:
- Does the teen take any mental medication that might affect mood?:*
  
  YesNo
- If Selected Yes above, please explain:
- Are you an Inlivian resident?*
  
  YesNo
- Are you currently a Families First participant?*
  
  YesNo
- What level will your teen participate:
  
  Event Only- Teen will only attend events during sessionFierce Teen- Full Mentoring Program- Active Participation Required for 18 week sessionELITE TEEN (This option is ONLY for returning teens that were given Elite status)
- 1- Event Only- In this level, teen will only attend events held by Fiercely Changing the Game. Teen will not receive a workbook, will not be required to follow FCG program and will not have scheduled one on one meetings (meetings may be requested)
  
  2- Fierce Teen- Original program, teen will receive a workbook, attend events, be on rotation for one on one meetings and will be required to be active in the 18 week session
  
  3- Elite Fierce Teen- INVITE ONLY- teen has completed at least one session, completed the workbook assignments and were given elite status by FCG mentors- teens will follow a leadership/life skills program.
- Disclaimer
  The information entered above is accurate and detailed to the best of my knowledge. All information obtained by FCG is confidential and only used for the purpose of mentee informational purposes. This program is designed for personal and professional growth, and as such, boundaries need to be adhered to. This will ensure the integrity of the mentoring program. It is not acceptable to share proprietary or sensitive information at any time. FCG will not assume any legal liability issues or legal proceedings that arise from this program. The participant(s) will hold FCG harmless from any damages that occur. The participant acknowledges that FCG and their directors, officers, representatives and agents are NOT responsible for errors, omissions, acts or failures to act on any part of conducting activities on behalf of FCG. Anyone participating in the program does so voluntarily, and should rely on their own independent judgment, in determining the exercise of reasonable care in any given circumstance. I have read and understood the guidelines for the FCG and agree to follow these guidelines.
- Do you Accept Disclaimer?:*
  
  Yes
- COVID Waiver
  I am fully and personally responsible for my teens safety and actions while and during participation and I recognize that I may in any case be at risk of contracting COVID-19. With full knowledge of the risks involved, I hereby release, waive, discharge the Fiercely changing the Game Organization, its board, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me or my teen related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19. I agree to indemnify, defend, and hold harmless Fiercely Changing the Game Organization from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.
- Do you Accept COVID Waiver?*
  
  Yes
- Signature*
- Enter the message as it's shown*
- Should be Empty: