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T.A.R.G.E.T.S – Young Men and Women Mentoring Program

Consent & Liability Waiver • Interactive Form

Participation Consent

T.A.R.G.E.T.S is a youth mentoring program empowering young men & women through consistent guidance, real-life wisdom, and practical tools to overcome obstacles through:

Leadership development
Wellness and personal growth
Group mentoring and supportive conversations

Complete the form below. You can save, print, or export a copy for your records.

Instructions

Fill out participant info and guardian info (if participant is under 18).
Review the waiver, confidentiality notice, and media release selection.
Sign (type your name or draw a signature).
Click Submit Form to send to program leaders, or Print for a paper copy.

Note: Clicking "Submit Form" will send your information securely to the program leaders via email. Use "Save Draft" to store locally in your browser, or "Print" for a paper copy.

Participant Information

Participant Name

Required.

Date of Birth

Required.

Grade (or School Year)

Age

We'll try to calculate from DOB.

Participant under 18?

Parent/Guardian Information (required if participant is under 18)

Parent/Guardian Name

Required for participants under 18.

Phone Number

Required for participants under 18.

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 are not liable for any injury, loss, accident, or harm that may occur during participation. I release and discharge Breaking Through Road Blocks along with any volunteers or partners, from any claims arising from program involvement.

You must acknowledge this to proceed.

Emergency Medical Authorization

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

Emergency Contact Name

Required.

Emergency Contact Phone

Required.

Allergies / Medical Needs (if any)

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

I understand the confidentiality notice above.

Required.

Media Release (Select 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.

Please select YES or NO.

Signatures

You can type your name and/or draw your signature. Printing will include the drawn signatures.

Parent/Guardian Typed Name

Required.

Date

Required.

Parent/Guardian Signature (Draw)

Participant Typed Name (recommended)

Date

Participant Signature (Draw)

Participation Consent

Instructions

Participant Information

Parent/Guardian Information (required if participant is under 18)

Assumption of Risk & Liability Waiver

Emergency Medical Authorization

Confidentiality Notice

Media Release (Select One)

Signatures

T.A.R.G.E.T.S. Consent Form