Mentoring Program Application - Men of Action & Women of Action

Youth Information





School Info


Parent/Guardian Information


Contact Information





Emergency Contact



Child/Youth Traits


Mental Health

Child/Youth Exposure to Trauma

Program Interest (Please answer all of the following questions as completely as possible)



Parent/Guardian Consent, Acknowledgment, and Authorization

Please read each of the following statements carefully. For each statement, indicate your agreement by selecting "Yes" or "No."


(1) Participation Consent
I acknowledge that I am the parent or legal guardian of the child identified in this application and hereby give my informed consent and permission for my child to participate in the Men of Action/Women of Action (MOA/WOA) Mentoring Program conducted in collaboration with Big Brothers Big Sisters of the Tennessee Valley (BBBSTV), including all program-related activities.


(2) Program Rules and Expectations
I understand that my child is expected to comply with all policies, procedures, rules, and behavioral expectations established by BBBSTV and the MOA/WOA Mentoring Program. I acknowledge that failure to comply with these requirements may result in my child's suspension or dismissal from the program.


(3) Transportation Acknowledgment
I acknowledge and agree that I am solely responsible for arranging and providing transportation for my child to and from all activities associated with the MOA/WOA Mentoring Program. I understand that BBBSTV, MOA, WOA, and their respective officers, staff, mentors, volunteers, representatives, and partnering organizations do not provide transportation as part of this program.


(4) Release of Liability and Hold Harmless Agreement
To the fullest extent permitted by law, I voluntarily release, waive, and discharge Big Brothers Big Sisters of the Tennessee Valley (BBBSTV), Men of Action (MOA), Women of Action (WOA), and their respective officers, directors, employees, mentors, volunteers, representatives, and partnering organizations from any and all claims, demands, causes of action, liabilities, damages, losses, or expenses arising out of or related to my child's participation in the MOA/WOA Mentoring Program. I further agree to indemnify and hold harmless BBBSTV, MOA, WOA, and their respective officers, directors, employees, mentors, volunteers, representatives, and partnering organizations from any claims arising from my child's participation in the program, except to the extent such claims result from gross negligence or willful misconduct.


(5) Photo, Video, and Media Release
I grant permission to Big Brothers Big Sisters of the Tennessee Valley (BBBSTV), Men of Action (MOA), Women of Action (WOA), and their partnering organizations to photograph, video record, or otherwise capture my child's likeness, voice, or image while participating in the MOA/WOA Mentoring Program. I understand and agree that these photographs, videos, recordings, and other media may be used without further notice or compensation for promotional, educational, marketing, fundraising, public relations, and other program-related purposes in print, digital, online, social media, or other communication platforms.


Signature of Parent/Guardian/Legal Caregiver

After receiving the completed application form, we will evaluate the information and notify you of whether yoru child has been accepted in the mentoring program. Please email the Program Manager, Mike Topps, at the following email address with any questions: mtopps@bbbstv.org