Student Information
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Untitled Title
Student First Name *
Student Last Name *
Age of student *
Birthdate of Student *
MM
/
DD
/
YYYY
What grade is the student currently in. (If you are completing this over the summer, indicate what grade he is going into) *
What school does your child attend. *
What is your child's cell phone number. If s/he doesn't have one, please keep it blank.
What is the child's primary address. Include street, city, state and zip code. *
Indicate if there is an alternate address we should also use.
Please indicate if you child has any allergies.
Please indicate your child's t-shirt size. *
Required
During the course of our program, you child will be engaged in various physical and sporting activities. Does your child suffer from any medical conditions that the program should be aware of. *
If you replied yes and not sure, please provide a description of the condition.
How do you hope a mentoring relationship will benefit your child? *
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