PROGRAM INTEREST [Please check all you are interested in]


    I , , agree to participate in Youth Empowerment Zone(YEZ) Programs [up to the 22nd birthday or until voluntarily or involuntarily terminated]. I agree that I will not hold YEZ or any staff liable for any damages or injuries that may occur while participating in YEZ programs by signing this document.


    I herby authorize the Youth Empowerment Zone Programs to release and obtain personal information concerning (Participants Name) for the purpose ofassisting me or my son/daughter with obtaining employment, mentors, entrepreneurship and continuing education goals. I understand this information will only be used to ensure quality services. No information obtained will be re-released without my express permission.


    I hereby grant permission to be photographed/ interviewed voluntarily and without compensation, understanding that the same is intended for publication by print media, newspaper, television, or video.

    I additionally consent to the use of my name in connection with the publication by print media, newspaper, television, or video of photographs taken of me.

    EMERGENCY CONTACT [Someone to contact in case of emergency]:


    1. I hereby consent to allow my minor child/ward to take part in the activities at the Youth Empowerment Zone. I understand that information about my child/ward and my family may be shared among Program staff and that the staff is required to keep such information confidential.

    2. My child/ward’s part in this program:

    a. He/she will answer a group of questions about him/herself in an effort to match him/her with a mentor, to evaluate the program, and most importantly to help staff learn how to best support him/her

    b. He/she will spend approximately one hour a week with his/her mentor

    c. He/she will fully participate in all or most sessions (at least 90%) of the Programs

    3. How this program hope to help my child/ward:

    a. Help him/her form a friendship with a volunteer mentor

    b. Provide opportunity for him/her to learn new life and job skills

    c. Provide opportunity to fully explore education and career options

    4. I give Program staff my permission as the parent/guardian of this child to obtain attendance and academic (grade reports) records from my child/ward’s school in order to help Program better serve my child/ward whenever Program staff deems it necessary.

    5. In addition:

    a. I understand that his/her participation in this program is voluntary and that he/she can choose to leave at any time.

    b. He/she has been told that if it is revealed that he/she has been abused that it will be reported to the proper authorities and that any information given while in this program may be subpoenaed and told in court.

    c. I understand that the Program staff will keep any information (except for that in b. above) about me and my family confidential.

    All my questions about the program have been answered. If I have any further questions about this program, I can contact Program Staff


    I (print name) agree to participate in Youth Empowerment Zone [YEZ] programs. I understand that:

    • Youth Empowerment Zone is a drug free environment. I will not attend programs under the influence of any controlled substance or alcohol. I agree to be prepared and read to work (sober).
    • While attending JRT I agree to participate in all activities.
    • An important part of YEZ programming is mentorship support. My mentor is there to act as a friend and support person. The mentor relationship may go beyond job/career boundaries, but if it is extended, my mentor and I will mutually agree upon it.
    • I must participate in job readiness or career development training that may be required to improve my job hunting skills and employability.
    • It is my responsibility to find a job. Staff will help me by providing leads, references, and support.(initial)
    • I will be on time for job interviews and follow the employers’ instructions given at the interview.
    • I will contact YEZ program staff upon completion of any interview with an employer in order to discuss the results of the interview process.
    • I must remain employed at my job-site for at least (3) months once hired.
    • I will discuss any possibilities of resigning or leaving an employer with the YEZ program staff prior to submitting a resignation.(initial)
    • YEZ program staff may share information regarding my background and/or placement history that will be used to facilitate employment and the match relationship. All information will be held in the strictest confidence. Mentors participating in the program will sign statements of confidentiality to further protection of information

    I agree to follow the following process to help me find and retain employment:

    • I will attend and successfully complete 15 hours of JRT.
    • I will follow through with job leads (contact employers, fill out applications, dress appropriately for interviews)
    • After obtaining employment, YEZ staff will maintain contact with my employer and me. If there are problems that I need help with, I will immediately contact YEZ staff.
    • YEZ will conduct monthly support group meetings. I pledge to attend and actively participate at each monthly support group meeting. (initial)