Mentor Release Statement

I, the undersigned, hereby state that if accepted as a Mentor, I agree to abide by the rules and regulations of the Girls/Boyz First!! Mentoring Program.

• I understand that I am required to successfully complete a training session or personal training orientation and communicate regularly with the mentor coordinator during my mentoring period.
• I certify that I have not been convicted of any felony, or of a misdemeanor classified as an offense against a person or family, of public indecency, or of any violation involving a state or federally controlled substance. I am not under current indictment, and no criminal charges are currently pending against me.
• Further, I hereby fully discharge Girls/Boyz First!!, Community Connections and Central Vermont New Directions from any and all liability, claims, causes of action, costs and expenses which may be attributable to my participation in the Girls/Boyz First Mentoring Program.

I have read the above Release Statement and agree to its contents. To the best of my knowledge and belief, all statements in this profile are true and accurate. I agree to promptly advise Girls/Boyz First!! in writing if any information in the application changes. I also agree that Girls/Boyz First!! has my permission to conduct a full background check on me for any criminal convictions.

________________________________________________________

Signature Date