I'RAISE Girls & Boys International Corp. Full Application for Virtual Mentoring Services
Our virtual mentoring program provides one on one emotional and social support to children and youth ages 5-18 years of age. This application is required to register your child for virtual mentoring and gives I'RAISE Girls & Boys International Corporation consent to provide virtual mentoring services to your child. Please complete one form for each child.
Name of Child (First and last name) *
Your answer
Child Date of Birth *
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DD
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YYYY
Child Gender *
Which best describes the race/ethnicty of your child? *
Address (House Number) *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Name of the School Child Attends *
Your answer
What Grade is your Child in? *
Your answer
Does any of the following apply to your child: *
Required
Emergency Contact Name (Other than primary caretaker)(First and last name) *
Your answer
Emergency Contact Mobile Number *
Your answer
Emergency Contact Email Address *
Your answer
Emergency Contact Full Address (House Number, Borough, Zip Code, City, State) *
Your answer
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