Individual Match Closure Agreement

INDIVIDUAL MATCH CLOSURE AGREEMENT

Legal Guardian Name*
Youth Name*
Match Date*
Date Format: MM slash DD slash YYYY
Closure Date*
Date Format: MM slash DD slash YYYY
- By checking the box below, I am acknowledging that I have met with the mentor and program staff and all parties have agreed to close the match.
- By checking the box below, I understand and agree that as of this date the youth is not permitted to engage in any activities or contact with the Mentor (e.g. scheduled or unscheduled visits, activities, meetings in the community or beyond, public places, designated site, said Mentor’s home or mine, or by any other means including via telephone, e-mail, text or social media) under the auspices and supervision of Rogue Valley Mentoring. Any such contact will be the full responsibility/liability of the Mentor and the Mentee’s parent/guardian. Details of their continued friendship is described in the Friendship Pact form.
- By checking the box below, I hereby fully release, discharge and hold harmless Rogue Valley Mentoring, participating organizations and all of the foregoing employees, officers, directors, and coordinators from any and all liability, claims, causes of action, costs and expenses which may be or may at any time hereafter become attributable to my participation in and termination from Rogue Valley Mentoring.
Acknowledgement*
- I acknowledge and agree to all terms stated in this agreement
Signature*
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