FMOT Complete Registration

Mentee First Name

Mentee Last Name

Date of Birth

Month

Day

Year

Grade

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Mentee

School

Parent Phone Number

Parent Email Address

Home Address

Pickup 1 First Name

Pickup 1 Last Name

Pickup 1 Relationship

Pickup 1 Phone Number

Pickup 2 First Name

Pickup 2 Last Name

Pickup 2 Relationship

Pickup 2 Phone Number

Pickup 3 First Name

Pickup 3 Last Name

Pickup 3 Relationship

Pickup 3 Phone Number

Pickup 4 First Name

Pickup 4 Last Name

Pickup 4 Relationship

Pickup 4 Phone Number

Pickup 5 First Name

Pickup 5 Last Name

Pickup 5 Relationship

Pickup 5 Phone Number

Emergency Contact 1 First Name

Emergency Contact 1 Last Name

Emergency Contact 1 Relationship

Emergency Contact 2 First Name

Emergency Contact 2 Last Name

Emergency Contact 2 Relationship

Known Allergies

Current Medications

Medical Conditions

Physician Name & Phone Number

Emergency Contact 2 Phone Number

Emergency Contact 1 Phone Number

Photo & Media Release: I grant the Omicron Upsilon Lambda Chapter of Alpha Phi Alpha Fraternity, Inc. and the OUL Foundation permission to photograph/record my child and use his image, likeness, and voice for the Program's promotional, educational, and historical purposes, with no compensation. I have read and agree.

Transportation & Field Trip Consent: I authorize my child to participate in Program field trips and off-site activities and to be transported by Program representatives or approved vehicles to and from these events. I have read and agree.

Assumption of Risk & Waiver of Liability: I understand participation involves inherent risks (including travel, field trips, and physical activities) that may result in injury. I voluntarily assume these risks and, to the fullest extent permitted by law, release and discharge the Chapter, Alpha Phi Alpha Fraternity, Inc., the OUL Foundation, and their members, mentors, and volunteers from claims arising from ordinary negligence. This does not apply to gross negligence or intentional misconduct.

Parent/Guardian Signature

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Electronic Signature Consent (ESIGN/UETA): By typing your full legal name above and submitting this form, you agree that your electronic signature is the legal equivalent of your handwritten signature, you intend to be bound by all consents and agreements in this form, and the information you provided is true and accurate. You certify that you are the parent or legal guardian with authority to sign for the participant.

Date Signed

Month

Day

Year

Indemnification & Hold Harmless: To the fullest extent permitted by law, I agree to indemnify, defend, and hold harmless the Chapter, Alpha Phi Alpha Fraternity, Inc., the OUL Foundation, and their members, mentors, and volunteers from any claims, losses, or expenses (including attorneys' fees) arising from my child's participation or any act or omission of my child, except those caused by their gross negligence or intentional misconduct. I have read and agree.

Emergency Medical Treatment & Portal/Data Consent: If my child is injured or ill and I cannot be reached, I authorize Program representatives to obtain emergency medical care for him, and I accept financial responsibility for care not covered by insurance. I also consent to the Program creating a parent portal account for me and storing this information and my child's progress notes to operate the Program. I have read and agree.

Mentee First Name

Mentee Last Name

Date of Birth

Month

Day

Year

Grade

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Mentee

School

Parent Phone Number

Parent Email Address

Home Address

Pickup 1 First Name

Pickup 1 Last Name

Pickup 1 Relationship

Pickup 1 Phone Number

Pickup 2 First Name

Pickup 2 Last Name

Pickup 2 Relationship

Pickup 2 Phone Number

Pickup 3 First Name

Pickup 3 Last Name

Pickup 3 Relationship

Pickup 3 Phone Number

Pickup 4 First Name

Pickup 4 Last Name

Pickup 4 Relationship

Pickup 4 Phone Number

Pickup 5 First Name

Pickup 5 Last Name

Pickup 5 Relationship

Pickup 5 Phone Number

Emergency Contact 1 First Name

Emergency Contact 1 Last Name

Emergency Contact 1 Relationship

Emergency Contact 2 First Name

Emergency Contact 2 Last Name

Emergency Contact 2 Relationship

Known Allergies

Current Medications

Medical Conditions

Physician Name & Phone Number

Emergency Contact 2 Phone Number

Emergency Contact 1 Phone Number

Parent/Guardian Signature

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Date Signed

Month

Day

Year