Swimming Upstream Participant App.

UPLIFT San Diego

Swimming Upstream Program

Student Enrollment Form

UPLIFT San Diego’s Swimming Upstream Teen Mentoring Program is designed to provide middle school students with mentorship, life skills, and personal growth opportunities through engaging workshops led by dedicated volunteer mentors and community partners.

The program runs for a minimum of two hours per day over four sessions, covering topics such as mental wellness, healthy relationships, financial literacy, and future goal-setting. Each student receives consistent guidance from a mentor in a supportive and uplifting environment.

To enroll, a parent or guardian must complete this registration packet for each student participating. Your responses will help us tailor the program to best support you.

If you have any questions, feel free to contact us at info@upliftsandiego.org.

Student/Participant Information:

Workshop Selection

Superpower Workshop (3/15, 3/22, 3/29 and 4/5/2025)

Contact me about future workshops

Other

Select one or more options

First name

Last name

Preferred Name (if different)

Date of Birth

Month

Day

Year

Grade Level

School Name

Gender

Race/Ethnicity

Is the student part of the LGBTQIA+ community?

Providing this information helps us pair students with mentors who can best support and relate to their unique experiences.

Preferred Answer

Free or Reduced Lunch Status (Yes/No)

Parent/Guardian Contact Information:

The guardian listed on this form will serve as the primary point of contact for UPLIFT staff and the volunteer mentor. They will be responsible for picking up the student from the program or informing staff of any approved individuals authorized to do so in their place.

Parent/Guardian Full Name

Relationship to Participant

Home Phone (please add 1 in front of phone number)

Cell Phone (please add 1 in front of phone number)

Home Address (Address, City, State, Zip/Postal Code

Emergency Contact Information:

Emergency Contact Full Name

Emergency Contact Relationship to Participant

Emergency Contact Phone

Emergency Contact Email

Emergency Contact Preferred Language

Terms of Service

Please confirm all statements and sign this form on behalf of the student named above, agreeing to the Terms of Service and program participation.

Parent/Guardian Confirmation: By checking this box, I attest to being the legal guardian of this student named above. I hereby allow them to participate in all activities and functions scheduled for the Swimming Upstream mentorship program.

Religious Content: By checking this box, I confirm that I understand UPLIFT has a non-discrimination policy and does not require any

faith affiliation to participate in any UPLIFT programming. However, I understand that the Swimming Upstream program has an opening and ending group activity that includes a “Blessings Box” which allows participants to share their faith with others if interested.

Media/Publicity Release: By checking this box, I confirm that I understand and consent to UPLIFT and its community partners, including but not limited to the San Diego Council on Literacy and Live Well San Diego, using my child’s image and likeness for promotional and marketing purposes. This may include, but is not limited to, brochures, presentations, newsletters, and social media content. My child’s likeness may be captured in various forms, such as photos, videos, and success stories.

Confidentiality and Mandated Reporting: By checking this box, I confirm that I understand all information regarding my child’s participation in the Swimming Upstream Program is kept confidential between UPLIFT staff, the guardian, the school, and the assigned volunteer mentor. However, confidentiality may be broken in cases where there is suspected child abuse, elder abuse, intent to self-harm, or intent to harm others, in accordance with mandated reporting laws.

I pledge to: (1) ensure that my child attends and actively participates in all mentoring sessions, notifying the UPLIFT Student Services Manager as soon as possible if my child will be absent for any reason, (2) make sure my child is prepared for each mentoring session by bringing all necessary supplies, and (3) encourage my child to engage fully, demonstrate good behavior, and adhere to all program policies and procedures at all times.

I am signing on behalf of (Student/Participant name)

Parent/Guardian Print Name

Date

Month

Day

Year

Parent/Guardian Signature