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L.U.C.K.Y. Leadership Mentoring Program Registration 2022-2023
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Email
*
Your email
Name of future l.u.c.k.y. parent
*
Your answer
Name of future L.U.C.K.Y. mentee
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Your answer
Parent Phone Number
*
Your answer
Parent Email
*
Your answer
Family Address for L.U.C.K.Y. mentee
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Your answer
How old is your child?
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Your answer
What grade is your L.U.C.K.Y. mentee in?
*
Your answer
Select location.
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Mallery/ Rumph Recreation Center 100 East Johnson Street
Community Center at Visitation 2646 Kensington Ave
Cecil B Moore Recreation Center 2551 N 22nd Street
Virtual Only
During the program, we may take photos/videos/audio recordings of participants to use in promoting L.U.C.K.Y. Mentoring Program Organization in general. Do you consent to your child being photographed or recorded by us for the above purpose?
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Yes
No
Please share any known allergies of your child/teen.
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Nut Allergy
Lactose Intolerance
Gluten Intolerance
None
Other:
Required
Emergency Contact Name:
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Your answer
Emergency Contact Phone Number
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Your answer
Emergency Contact Address
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Your answer
How did you find out about the L.U.C.K.Y. Mentoring Program
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L.U.C.K.Y. Email Newsletter
L.U.C.K.Y. Social Media
L.U.C.K.Y. Organization Member
L.U.C.K.Y. Website
Partner site i.e. CB Moore, Mallery or CCV
Does your child need any special accommodations of any kind?
*
Yes
No
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