Girls: Sign Up | T.A.R.G.E.T.S.

Assumption of Risk & Liability Waiver

I understand that participation may involve minimal risks, including emotional discussions or group activities.

To the fullest extent permitted by law, I agree that Breaking Through Road Blocks organization and staff: Dominique Ellis and Di’Andra Alves are not liable for any injury, loss, accident, or harm that may occur during participation in this mentoring program.

I release and discharge Breaking Through Road Blocks, Dominique Ellis and Di’Andra Alves, along with any volunteers or partners, from any claims arising from program involvement.

Emergency Medical Authorization

In the event of an emergency, I authorize program leaders to seek medical care and/ or be transported to the nearest local hospital if I cannot be reached.

Participant First Name

Participant Last Name

Date of Birth

Grade

(participant under 18 required)

Parent/Guardian First Name

Parent/Guardian Last Name

Phone Number

Emergency Contact Full Name

Emergency Contact Phone

Confidentiality Notice

This program is a safe space. Privacy is respected; however, confidentiality may be broken if a participant discloses:

Harm to self or others
Abuse or unsafe situations
Information requiring mandated reporting

Media Release (Please Check One)

Yes. I allow photos/videos of my child/ participant for program-related use.

No. I do not allow my child’s image to be shared publicly.

Signatures

By signing, I confirm I understand and agree to the T.A.R.G.E.T.S.-Young Women Mentoring Program Consent and Liability Waiver.

Parent/Guardian Signature

Parent Sign Date required

Participant Signature

Participant Sign Date required

Thanks for Siging Up!

BREAKING THROUGH ROADBLOCKS

Emergency Medical Authorization

Confidentiality Notice

Media Release (Please Check One)

Signatures