Concerned Black Men National

CBM CARES®Oakland, CA

STUDENT/PARENT INFORMATION FORM

***Please be advised that all information collected in this document will be kept strictly confidential and will only be used for the purposes of the CBM CARES® Mentoring Program. This information will not be shared with,nor disseminated to, any other entity without the express permission of the parent/guardian. Please answer all applicable questions in full detail so that we may better serve your child.

Contact Information

Student: Last Name / First Name / Middle Initial
Mother: Last Name / First Name / Father: Last Name / First Name
School Name / Student Grade and ID Number
School Street Address / Home Address
SchoolCity / State / Zip / HomeCity / State / Zip
School Phone / Home Phone / Business Phone
Homeroom Teacher / Mobile Phone / Preferred Phone
Business Home
Mobile
Has your son repeated a grade? __Yes __No Grade?___ Reason _____ / Email address:
Birth date (month, day & year )
Month Day Year / Primary Religion / Ethnic Origin
Parent/Guardian(s) Names

1. Is mentee enrolled in Special Education? ____Yes ____No If yes, what services does he receive?

______
______
______

2. Is menteeenrolled in Honors, Accelerated, or Advanced Placement Classes? ____Yes ____No If yes, what classes, and where is he taking the class(es)? ______
______

3. Is there any other background information you wish to share with CBMCARES® at this time?

______
______
______
Please check all applicable boxes. This survey will help to inform CBMCARES® of your son’s needs and interests. The answers to these questions are essential to the mentor/mentee matching process.
Medical Conditions: ____ Allergies (List) ______

_____Asthma _____Diabetes _____Rheumatoid Arthritis_____ Other (List): ______

Disabilities: Check all that Apply: ____Mental ____Physical _____Other (List)______
Home Life-Family: ____Mother in Home ____Father in Home

____ Other Adults in Home (List their relationship to mentee) ______

Are there siblings in home? ____Yes ____No How many? ____Brothers ____ Sisters

Financial:HouseholdIncomeRange: $_____$10,000-$39,999 $_____$31,000-$48,999

____$49,000-$50,999 ____$51,000 and above ____Public Assistance (Type____)
Does mentee receive an allowance? __Y__N ____Allowance (If Yes, How Often) ___Weekly ___Monthly

Mentee History: ____Substance Abuse in Home ____Physical Abuse _____Sexual Abuse

____Emotional Abuse _____Enrolled in Counseling _____Other (Please Specify______)

Behavioral/Therapeutic: ____Aggression ____Anger Management ____ADHD ____Depression ___Other (List______)

Communication Skills: ____Introvert (Personal) ____Extrovert (Outgoing/Social) ____ Other (List______)

Does mentee engage in any behaviors listed below?

____Alcoholic Consumption ____Smoking

____Drug Use ____Excessive Caffeine

____Un-prescribed medicines ____Other (list)______

Misc (Check all that Apply): ____Foster Care ____Adopted ____Gang involvement ____Run Away ___Immigrant ____Incarcerated Parent (If yes:___Mom ___Dad) ____Parent(s) in Military ____

Pregnant Mother ____Criminal History: Explain______

______
______

List mentee’s strengths? (ex: leadership, focus) ______

______

List mentee’s weaknesses? (ex: peer pressure, shy) ______

______

List specific area(s) in which your son needsmentoring:____________

Concerned Black Men National

CBM CARES®Oakland, CA

MENTEE ASSENT FORM

I ______, having my parent’s/guardian’s permission to participate in the CBM CARES® Oakland, CA therefore enter into this agreement with the Concerned Black Men of Oakland, CA. I understand that the mentor is a volunteer who wants to help me to be successful in school, in life, and will act as a friend, advisor and role model. I also understand that there is no monetary assistance provided by the mentor or the program.

I understand that the mentor agrees to interact with me for 12 months, at least 8 hours per month, some of which could be over the phone. In return, I agree to try hard to have a good relationship with the mentor. I also promise to:

Keep all appointments with my mentor and BE ON TIME.
Follow all rules and guidelines as outlined by the program coordinator, mentee training, program polices and this agreement.
Have a positive attitude and be respectful of my mentor.
Meet at least eight hours per month with my mentor which includes phone and email contac.t
Call my mentor at least 24-hours before hand if I am unable to make a meeting.
Inform the program coordinator of any difficulties or areas of concern that may arise in the relationship.
Participate in a closure process when that time comes and complete a survey at the end of the year.
Notify the program coordinator if I make changes in my personal information, address, phone, etc.
Attend mentee training sessions as scheduled.
Respect the guidelines set by my mentor.
Attend all required program activities.

I understand that if I miss three mentoring sessions without a valid excuse, I may loose the privilege to participate in the CBM CARES® Oakland, CA.

____/_____/____

Mentee/Student Date

____/____/_____

CBM WitnessDate

If you have any questions, concerns and ideas pertaining to the project, please contact our

Program Staff at 510-465-2521 or via email at

Concerned Black Men National

CBM CARES®Oakland, CA

MEDICAL GENERAL LIABILITY RELEASE

(To be completed by the Parent/Guardian)

Student Name:______Date:______

School: ______

I______, the parent/authorized guardian of the above named student hereby release CBM CARES® Oakland, CA of all liability of injury, death, or other damages to me, my child, family, estate, or heirs, that may result from his participation in the program, including but not limited to those related to transportation, and hold harmless any CBM mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

In case of an emergency, I give permission for CBM to seek medical treatment for my son, In case of emergency please contact the following:

EMERGENY CONTACT:______Relationship:______

Phone Number:______Other Number:______

Address:______

SECOND CONTACT:______Relationship:______

Phone Number:______Other Number:______

Address:______

MEDICAL PROVIDER/PHYSICIAN: ______

Providers Address: ______

Office Number: ______Other Number:______

HOSPITAL/MEDICAL FACILITY OF CHOICE: ______

Phone Number: ______

INSURANCE PROVIDER: ______Group#:______

I.D. Number: ______Phone Number:______

MEDICAL HISTORY: Is your child being treated for any medical conditions at this time? If yes, please explain treatments, including any medications:______

Does your child experience any of the physical impairments listed below:

_____ Hearing Impaired______Seeing Impaired ______Physical Disability

Does your child require any special equipment to facilitate their daily activities, such as:

____Special equipment ______Walker ______Wheelchair ______Hearing_____ Glasses/Contacts

Please use the space below to inform us about any and all important information concerning the health and physical/mental/emotional status of your child.

Comments:

Parent/Guardian SignatureWitness Signature

______

DateDate