Intake Form

Consent for Participation

I authorize Better Wiser Stronger (BWS) Program to provide programming to my son:

* Indicates required field

Youth name *

Better Wiser Stronger, Inc. (BWS) provides methods to alter the life outcomes of young urban males. Our goal is to provide young men with opportunities to succeed. This approach is applied through mentoring, workshops/seminars and hands on experiential learning.

I understand that my participation and that of my child in this program is voluntary. I will receive a schedule detailing the location, time, and dates of all respective meetings.

I give permission for my child to attend scheduled field trips. I give permission for my child to be transported by authorized Better Wiser Stronger executive director, staff and volunteers.

I give permission for my child and myself to be photographed, interviewed, and/or televised for use in public relations communications through newspapers, magazines, books, movies, videotape, internet websites, or educational media.

I give permission for my child to participate in assessments, surveys and focus groups for the purpose of receiving feedback regarding Better Wiser Stronger Program.

Submit

Student Information

* Indicates required field

Full Name: (First / Middle Initial / Last) *

Date of Birth *

Age *

Race *

Please specify if Other *

Address *

Line 1

Line 2

City

State

Zip Code

Country

School *

Grade *

Youth Cell Phone *

Youth Email *

Parent/Guardian Name *

Relation *

Home Phone *

Cell Phone *

Parent Email *

Submit

Emergency Contact Information

* Indicates required field

I (parent name), *

grants permission to Better Wiser Stronger organization to seek emergency treatment for my son:

(Participant’s name) *

if necessary and I agree to accept financial responsibility for the costs related to this emergency treatment. In the event a Better Wiser Stronger staff member or volunteer cannot reach me, please contact the following Emergency Contact Person I have designated.

Emergency Contact Name *

First

Last

Home Phone *

Cell Phone *

Medical Information

Preferred local hospital *

Physician’s Name *

Phone *

Youth’s Allergies *

Insurance Information (if available)

Company *

Policy # *

Comments (include any special medical or personal information you would want an emergency care provider to know – or special contact information. *

Submit

Waiver of Liability, Assumption of Risk & Indemnity Agreement

* Indicates required field

Participant's Name *

First

Last

Waiver: In consideration of being permitted to participate in any way in hereinafter called Better Wiser Stronger activities, I, for myself, my heirs, personal representative or assigns, do herby release, waive, discharge, and covenant not to sue Better Wiser Stronger, its officers, employees, and agents from liability from any and all claims including the negligence of Better Wiser Stronger, its officers, employees, volunteers and agents, resulting in personal injury, accidents or illnesses (including death) and property loss arising from, but not limited to, participation in Better Wiser Stronger program.

I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in the program. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD Better Wiser Stronger HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in the program and to reimburse them for any such expenses incurred.

Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of Michigan and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

Submit

Intake Form

​Consent for Participation

Student Information

​Emergency Contact Information

​Medical Information

​Insurance Information (if available)

​Waiver of Liability, Assumption of Risk & Indemnity Agreement

Consent for Participation

Emergency Contact Information

Medical Information

Insurance Information (if available)

Waiver of Liability, Assumption of Risk & Indemnity Agreement