PERSONAL INFORMATION FORM

If yes, please explain (i.e. depression, deliberate but non-suicidal self-harm, anxiety, etc)
If yes, please provide details.
If so, please provide information that may be helpful for us to know as we work with your child.
If yes, please explain
Confidential Information: It is important to note, that the following information is essential to evaluate what impact our program is having and how to maximize our impact and will be solely used for the purpose of evaluating the needs of your daughter. All information that is provided to us, is held under strict confidentiality. Your cooperation is very much appreciated.
Please Select One and answer all of the following questions as completely as possible.
Mentee Interest Survey This survey will help us know more about the child and her interests and help us find a good match. All mentees/mentors meet 1 hour per week and have weekly contact.
PARENT/GUARDIAN AGREEMENT Please read and check one box below. You the parent/guardian hereby permit your daughter ("Minor Participant") to participate in the iProjectDestiny event Program. The signature of a parent/guardian signifies that you have read IPD's Code of Conduct, as well as have knowledge and an understanding of the IPD policies and guidelines outlined within and both my daughter and I will adhere to those policies. I the parent/guardian understand that all individuals actively involved in your program will go through a background screening to ensure the well-being and safety of my daughter. I fully understand that my daughter’s involvement and participation in this program requires: An annual non-refundable fee of $25; A completed application and consent form; Transportation to/from meeting location is the sole responsibility of the parent/guardian; All parents/guardian must volunteer in some capacity for their daughter to participate; Acceptance of our Code of Conduct/Attendance policies.