T.A.R.G.E.T.S. · YOUNG MEN & WOMEN

Your next chapter
starts here.

Join a mentoring community built around leadership, wellness, personal growth, and supportive conversations.

Program leadersRoberto Cadet · Joseph Alves · Liseth Carey · DiAndra Alves

PARTICIPATION CONSENT

Let’s get to know you.

Complete the participant information, review the consent notices, and sign below. A parent or guardian must provide their information for participants under 18.

Begin your intake ↓

Consent & Liability Waiver · Fields marked * are required.

Participant Information

Participant Name

Date of Birth

Grade (or School Year)

Age

Calculated from date of birth; you may also enter it.

Participant under 18?

Parent/Guardian Information

Parent/guardian name and phone are required if the participant is under 18.

Parent/Guardian Name

Phone Number

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 Roadblocks organization and staff (Dominique Ellis and DiAndra Alves) are not liable for any injury, loss, accident, or harm that may occur during participation. I release and discharge Breaking Through Roadblocks, Dominique Ellis and DiAndra 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 transport to the nearest local hospital if I cannot be reached.

Emergency Contact Name

Emergency Contact Phone

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.

Media Release

Select one option 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.

Personal Check-In

Answer in your own words. There are no wrong answers; this helps your mentors know how to support you.

Are you managing your time and workload effectively?

What’s one area where you’d like to improve?

How are you handling stress and pressure?

Who do you feel confident talking to when you need help?

Parents

For the parent or guardian to complete. Your answers help mentors understand and support your young person.

What does your young person enjoy when they are not in school?

What do you think your young person is struggling with right now?

What is your preferred communication method regarding your young person participating in T.A.R.G.E.T.S.?

What areas would you like your young person to focus on?

Signatures

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

Parent/Guardian Typed Name

Date

Parent/Guardian Signature (Draw)

Participant Typed Name

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