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TQIM
Mentoring (The Queen in Me Project) (2Inspire 2Mentor 2Motivate 2Encourage)
* Indicates required question
Email
*
Your email
First Name and Last Name of Applicant
*
Your answer
Date of Birth of Applicant
*
MM
/
DD
/
YYYY
Grade Level of Applicant
*
(For 2023-2024 School Year)
Your answer
First Name and Last Name of Parent/Guardian (1)
*
Your answer
First Name and Last Name of Parent/Guardian (2)
*
Your answer
Address of Applicant
*
Your answer
City and State
*
Your answer
Zip Code
*
Your answer
Complete Address of Parent/Guardian (Please provide the complete address or write "same").
*
Your answer
Please answer the following question:
Participant lives with:
*
Mother
Father
Both
Other:
Required
Email of Participant
*
Your answer
Email of Parent Guardian(s)
*
Your answer
Phone Number of Parent/Guardian
*
Your answer
Do you wish for your daughter's mentor to contact her on her cell phone for check-ins?
*
Yes
No Use (The Parent /Guardian Number Listed)
Marital Status of Consenting Parent
*
Married
Single
Other:
What is your ethnicity?
*
Your answer
Annual Household Income
Less than $50,000 annually
More than $50,000 annually
More than $100,000 annually
Clear selection
Employment Status
*
Full time
Part time
Unemployed
Temporarily Employed
Freelance
There is no registration fee necessary to participate in this project
A copy of your responses will be emailed to the address you provided.
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