Intake, waiver, and mentor templates

Participant interest form

• Participant name, age, pronouns if they choose to provide them.
• Parent or guardian name and contact information, if applicable.
• Referral source: school, group home, nonprofit, family, veteran organization, other.
• Why the participant is interested in Interstice.
• Activities of interest: martial arts, fitness, mentorship, art, writing, nutrition, meal prep, leadership, volunteering.
• Transportation needs.
• Accessibility or accommodation needs.
• Anything staff should know to help the participant feel safe and supported.

Parent or guardian consent fields

• I understand that Interstice may include physical training such as conditioning, martial arts fundamentals, partner drills, stretching, and wellness education.
• I understand that participation may involve physical risk, including soreness, bruises, falls, or injury.
• I understand that youth may choose not to participate in a specific drill and may ask for support or space.
• I understand the program’s supervision, arrival, pickup, transportation, and emergency contact rules.
• I understand how to report a concern.
• I understand that media consent, story consent, and medical/emergency consent are separate decisions.

Health and emergency information

• Emergency contacts.
• Physician or clinic, if available.
• Allergies, medications, asthma, seizures, diabetes, heart conditions, mobility restrictions, recent injuries, or other relevant health notes.
• Food allergies and dietary restrictions.
• Permission to contact emergency services if needed.
• Preferred calming/support strategies if the participant becomes overwhelmed.

Media and story consent

Use a separate form. Do not bury this inside a general waiver.

• Consent to be photographed: yes/no.
• Consent to appear in video: yes/no.
• Consent to use first name: yes/no.
• Consent to use written quote or story: yes/no.
• Consent expiration date or review date.
• Right to revoke future use where practical.

Mentor screening and onboarding

• Full legal name and contact information.
• Veteran status or service background, if offered voluntarily and verified where appropriate.
• Relevant youth work, coaching, mentoring, or leadership experience.
• References.
• Background check authorization.
• Code of conduct acknowledgement.
• Boundaries policy: no unsupervised one-on-one contact, no private messaging with minors unless policy allows and logs it, no gifts or favors outside program rules, no transportation outside approved procedures.
• Mandated-reporting training acknowledgement.
• Trauma-informed practice orientation.

Weekly mentor check-in

• Participant attended: yes/no.
• Energy on arrival: low, steady, high, unknown.
• Strength observed this week.
• Support need observed this week.
• Any safety or boundary concern.
• Goal before next session.
• Follow-up needed by staff.

Incident or concern report

• Date, time, location.
• People involved.
• What happened, using plain facts.
• Immediate action taken.
• Injury, medical response, or emergency services.
• Parent/guardian or partner notified: who, when, how.
• Mandated reporting considered or completed.
• Follow-up owner and deadline.

Participant reflection card

• One thing I practiced today.
• One thing I handled better than before.
• One thing I want help with.
• One goal for next time.