APPLY

Terms & Conditions

Please read carefully before submitting: The information you provide may be used to assist your child during program participation. Therefore, Lipstick After Dark may need to share your information with community partners, to include the Social Worker, Counselor, School Counselor, Therapist, or school officials.

Guardians: Please complete both application and the Release of Information and Permission to Participate form.

Step 1:

LAD

Application for Participation

Lipstick After Dark Mentoring Program appreciates you and your child’s interest in her becoming a mentee. This application is to gain the consent of the parent/guardian to allow their daughter to participate in the Lipstick After Dark Mentoring Program. After receiving the completed application, we will review the information and a decision about your child’s acceptance into the mentoring program will be emailed to you. All mentees must attend a MANDATORY orientation before starting our program.

Please send any questions or concerns to lipstickafterdarkllc@gmail.com

My name is:

Relation to Mentee:

Mobile:

Street Address:

City:

State:

Zip Code:

Parent/Guardian Email:

Mentee's Name:

Mentee's Phone:

Mentee Email:

Date of Birth:

Pronouns:

Grade:

School:

Emergency Contact:

Mobile Phone:

Why do you and/or your child wish to participate in this program?

What are your expectations for the Lipstick After Dark Mentoring Program? Provide a brief description.

Is your child able to have contact with a mentor at least twice per month? (Sessions occur twice each month; every other Saturday)

If not, please provide an explanation.

Is your child currently experiencing any problems either at home, in school, or both?

If yes, please provide an explanation.

Has your child experienced any traumatic events that may need to be known to the mentor (eg. death in the family, abuse, divorce)?

If yes, please provide an explanation.

Please provide any additional background information that may be helpful to L.A.D. Mentoring Program in helping your child succeed.

I give my informed consent and permission for my child to participate in the L.A.D Mentoring Program and its related activities.

I accept

I agree to have my child follow all mentoring program guidelines and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship.

I accept

I release the L.A.D Mentoring Program of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any L.A.D mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

I accept

I agree to allow L.A.D Mentoring Program to use any photographic or video image of my child taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials. (optional) I understand I must return the Information Release Form along with this application, and that any incomplete information will result in the delay of my application being processed.

I accept

Today's Date

By selecting the box below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

I accept

Step 2:

PARENTS!

Release of Information & Permission to Participate

Once you have accurately filled and submitted your application, you may complete the process by filling out your Release of Information form. Click the button below to proceed to the release form.

APPLY

Terms & Conditions

Step 1:

LAD

Application for Participation

Step 2:

PARENTS!

Release of Information & Permission to Participate

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