BSMP Mentorship Program – Parental Consent Form

Please fill out the following form.

First name

Last name

Date of birth

Month

Day

Year

Age

Parent/Guardian Full Name

Relationship to Participant:

Phone Number

The Foundations Mentorship Program provides one-on-one mentorship for young girls and young women ages 12–22.

For participants under 18:

Sessions are conducted remotely via audio (not in person).
Sessions are mentorship-based and focus on guidance, life skills, goal setting, and personal development.
This program is not therapy, counseling, or medical treatment.

Future sessions may include virtual video sessions (e.g., Zoom), and parents will be notified in advance if that format changes.

I understand the nature and purpose of the Foundations Mentorship Program.

I give permission for my child to participate in one-on-one mentorship sessions.

I understand:

This is a mentorship program, not therapy or clinical counseling.
Sessions are conducted remotely.
If concerns arise regarding the safety or well-being of my child, I may be contacted.
The mentor reserves the right to discontinue mentorship if boundaries are not respected or if the program is not a good fit.

I declare that the info I’ve provided is accurate and complete.

Parent/Guardian Signature

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Date

Month

Day

Year

Emergency Contact (if different from parent listed above):

Name

Phone Number

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