Sample Client Agreement Form (Excerpted from The ACCESS Mentor Training Manual. Used with permission from the Mentor Coordinator Network, Grand Rapids, Michigan.) I have had the Mentoring Partners program explained to me, and I understand that by voluntarily choosing to participate I agree to work with my community volunteer(s) toward the goals of: a. b. c. I also agree to: a. Release and agree to hold harmless and indemnify [names of all involved agencies] and the volunteers of [name of your mentoring program], from any and all injuries, damages, costs and liability of any kind arising from the performance of this agreement and the provision of services to the client. This covenant shall bind the client's estate, successors, heirs and personal representatives. b. Understand that my mentoring team will protect my privacy but by law they must report to the appropriated civil authorities any involvement I may have in regard to child abuse, my confession of a felony, my intent to do bodily harm to another person, or my intent to commit suicide. c. Give permission to the mentor volunteers to share information with resource people, caseworkers, counselors, and [name of your mentoring program] staff who may be able to help me and my family. Client's name Client’s Signature Soc. Sec. # Volunteer Name Volunteer Signature Volunteer Recruiter Signature Agency Date | 
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