Thank you for your interest in registering your child(ren) for the Fall Session of the 2019-2020 OurRoots Mentorship Program!

Instructions:

  1. Please carefully review the general guidelines

  2. After reviewing the general guidelines, please complete the application.

  3. Once the application as been submitted, you will receive an email in 1-3 business days confirming your child(ren)’s registration for the Fall Session of OurRoots!

General Guidelines 

  • A participation fee of $225 per mentee is required per session (Fall Session: September-December / Spring Session: February-May). This will cover the cost of four (4) activities.**

  • If registering for full 2019-2020 school year (Fall AND Spring Session—8 activities), receive a $25 discount (per child)

  • The program fee will be billed to families 1 month prior to the start of the program and must be paid in full prior to the first activity 
    *Beginning 2019-2020 school year, there is no annual family registration fee required
    **If financial limitations should prevent you from services, please contact us as we have some scholarship money and a sliding fee scale available to help support those in financial need
    ***As of October 1, 2018: If paying by credit card, a 2.9% credit card fee will be applied to the invoice. No additional credit card fee will be applied to families paying by cash or check

  • The program fee covers the following items:

    • 4 activities per session (Fall Session 2019: September-December); (Spring Session 2020: February-May)

    • Entrance/admission fees for adoptees, mentors, and OurRoots staff only

    • Materials/supplies

    • Rental space (for OurRoots activities and OurFamily Discussion Group)

    • Fees for mentors (background checks, entrance/admission fees, training, etc.)

 
 
I am registering my child(ren) for *
If registering for full year of OurRoots, receive $25 discount (per child) at the time of Fall registration.
Mentee Information
First, Middle, Last
Mentee #1 Date of Birth *
Mentee #1 Date of Birth
First, Middle Last
Mentee #2 Date of Birth
Mentee #2 Date of Birth
Parent/Guardian Information
Parent/Guardian Phone #1 *
Parent/Guardian Phone #1
Parent/Guardian Phone #2
Parent/Guardian Phone #2
Parent/Guardian Address #1 *
Parent/Guardian Address #1
Parent/Guardian Address #2 (if different from Parent/Guardian #1)
Parent/Guardian Address #2 (if different from Parent/Guardian #1)
Child(ren) is in the custodial care of: *
Emergency Contact / Drop-off & Pick-up
Please list two (2) emergency contacts (and phone number) and list relationship to mentee(s)
Please list other individual(s) (besides parent/guardian) that have permission to pick up mentee(s) from OurRoots Activities. If none selected, your child(ren) will not be allowed to leave without the parent/guardian present)
Medical / Health Information
For planning purposes, please list any allergies, dietary needs/sensitivities, health conditions, or special services adoptee receives in school or daily life. Examples include: ADHD, asthma, diabetes, migraines, seizures, etc. Information will be kept private and only shared with those who need to know.
Mentee #1 Medications
Please select if any of the following are prescribed. Please note if mentee will bring to OurRoots in the following section.
Please list any other information regarding mentee (physical/mental health), or other considerations for OurRoots staff and mentors to take into consideration (e.g. allergies or other dietary needs) to help make the program a positive experience for your child.
Mentee #2 Medications
Please select if any of the following are prescribed. Please note if mentee will bring to OurRoots in the following section.
Please list any other information regarding mentee (physical/mental health), or other considerations for OurRoots staff and mentors to take into consideration (e.g. allergies or other dietary needs) to help make the program a positive experience for your child.
Disclaimer/Terms & Conditions *
I hereby give permission for my child(ren) to attend activities with AdopteeBridge staff & volunteers. The staff member(s) and volunteers who supervise my child(ren) are exempt from any liability for any injury my child(ren) may sustain while under their care and direction. This permission is given with the knowledge that the staff and volunteers will not assume personal responsibility for medical attention other than First Aid. Should it be necessary for my child(ren) to take medication while participating in this activity, I hereby give my child(ren) permission to self-administer their medication and, if my child(ren) cannot self-administer, I give permission to the responsible staff members or chaperones to administer or to assist in the administration of my child(ren)’s medication. I also give permission to the responsible staff members, chaperones, medical practitioners and medical facilities to use their judgement in obtaining and providing medical treatment for my child(ren) should it become necessary to do so. I agree to relieve the Location and participating adults from liability in connection with this request. In the event of an emergency, I authorize AdopteeBridge and volunteers to obtain medical and/or surgical treatment for my child(ren) at no cost to the organization or volunteer. I hereby release, in the event of any injury or illness, and if deemed necessary by AdopteeBridge staff to make whatever emergency measures (i.e., first aid, disaster evacuations) that are judged necessary for the care and protection of my child(ren) while under the supervision of AdopteeBridge. In the case of a medical emergency I understand my child(ren) will be transported to an appropriate medical facility by the local emergency unit for treatment if the local emergency resource (police, rescue squad, or fire department) deems it necessary. I understand program fees must be paid in full prior to the start of a session and no refunds will be given after the start of a session, nor shall any refunds be given for any missed activities. By clicking "yes," I hearby verify I have read AdopteeBridge's Disclaimer/Terms & Conditions and I fully understand, and accept the above conditions and permit my child(ren) to participate in OurRoots Mentorship Program conducted by AdopteeBridge.