2017SUMMER COLLEGE PREP CAMP

PERTINENT INFORMATION

SUMMER COLLEGE PREP CAMP

The SummerCollege Prep Camp provides participants with information and opportunities to prepare for success at the collegiate level. Students will discuss 1) how to select a profession, 2) how to select your college major, 3) selecting the college that best fits, 4) scholarships, 5) study skills, 6) test-taking, 7)leadership, 8) communicative skills, and 9) how to handle stress.

Dates:July 17th- July20th Time: 9 a.m. - 1 p.m.Location: Windsor Forest High School

Eligibility:100 participants, rising 9th – 12th graders with the $15 registration fee (no checks please, payment via cash or money order).

Student Information:

Name:______Age: ______Sex: □Male □Female

School ______GPA______

Email[s]: ______/ ______

Cell phone[s]: (______)______(______) ______

Current Grade Level (2017-2018): □9th □10th □11th □12th

Parent or Guardian Information:

Name:___ __ Date:___

Address: ______

City:______State:Zip:___

Phone:Alternate Phone:___

Email:___

Consent, Release and Waiver Form

I, ______, the parent and/or guardian of ______(“Mentee”), hereby give my consent for him/her to participate in the 100 Black Men of Savannah, Inc. (“Savannah 100”) youth mentoring programs. I also agree that:

  1. Program staff, volunteers, Collegiate 100, and members of the Savannah 100, have my permission to provide Mentee reasonable first aid and transportation to a health care facility in the event Mentee needs emergency medical attention. I agree to release any records necessary for treatment, billing, referral or insurance purposes in the event Mentee is transported to a health care facility for emergency medical attention.
  1. Pictures and video or audio recordings of Mentee participating in the Program are hereby released by me for use in appropriate news media (e.g. newspapers, radio, and television stations) and in the marketing materials for the Savannah 100 (e.g. website and brochure).
  1. In consideration of Mentee being allowed to participate in the program I agree on behalf of myself, Mentee,any other parent or guardian of Mentee, and any personal representative, agent, heir, successor or assign of the foregoing (hereinafter “Mentee’s parties”) to forever and irrevocably indemnify,hold harmless, waive liability, release and dischargeSavannah 100, 100 Black Men of America, Inc., Programstaff, and any corporate entities, officers, directors, members and employees related to any of the Programfrom any and allclaims, demands, causes of action, rights, costs and charges of whatever kind or nature, arising out of or related to any known or unknown, foreseen or unforeseen bodily or personal injury, death, or property damage, resulting from Mentee’s voluntary participation in Program.
  1. In consideration of Mentee being allowed to participate in the Program, I covenant and agree on behalf of Mentee’s parties that Mentee’s parties will not sue Program parties for any claims for damages arising from or related to Mentee’s voluntary participation in Program.
  1. Assumption of Risks: Engagement in Athletic Activities carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries and that participation in any physical activity involves peculiar risks that even when safety precautions are utilized, injuries can occur. I also understand that if I experience pain or physical discomfort during these activities I will decrease or stop participating. I am aware that personal health/accident insurance is my sole responsibility. I affirm that to the best of my knowledge, I do not have any medical condition or physical disability that will preclude my safe participation.
  2. I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in The Engagement of Athletic Activities and participation in attendant activities. I hereby assert that I knowingly assume all such risks.

I hereby acknowledge that I have read this form and agree to waive certain legal rights by signing this Consent, Release and Waiver.

BY: Date: ______

PARENT/GUARDIAN

scholarship section

Household Information

Household Size: □-1 □-2 □-3 □-4 □-5 □-6 □-7 □-8 □-Other ______[please specify]

Total Household Annual Income $ ______

Proof of Income: ______(W4s; Pay-Stubs; Award Letters; etc.)

Who is financially responsible for the child’s tuition? ______

In order to qualify for a private scholarship for the $15.00 participation fee, you must have an annual household income (before taxes) that is at or below the following amounts:

Household Size* / Maximum Income Level
(Per Year) / Your Family
(Check One)
1 / $15,171
2 / $20,449
3 / $25,727
4 / $31,005
5 / $36,283
6 / $41,561
7 / $46,839
8 / $52,117

*For households with more than eight people, add $5,278 per additional person.

Please complete the application and return a mail copy to the address listed below before

1 July 2017

100 Black Men of Savannah

ATTN: Dr. Zke Zimmerman

P.O. Box 14606

Savannah, GA 31416-1606

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