MENTEE REGISTRATION FORM
YOUTH INFORMATION
Name (First Middle Last) *
Your answer
Age *
Your answer
Birthdate *
MM
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DD
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Address (Street, Apt. #, City, State, Zip Code) *
Your answer
Current School and Grade *
Your answer
Ethnicity (Choose those you identify with)
T-Shirt Size *
Required
PARENT/GUARDIAN INFORMATION
Mother/Guardian 1: Name (First Last) *
Your answer
Mother/Guardian 1: Phone Number (Home)
Your answer
Mother/Guardian 1: Phone Number (Mobile)
Your answer
Mother/Guardian 1: Phone Number (Work)
Your answer
Mother/Guardian 1: Email Address
Your answer
Father/Guardian 2: Phone Number (Home) *
Your answer
Father/Guardian 2: Phone Number (Mobile)
Your answer
Father/Guardian 2: Phone Number (Work)
Your answer
Father/Guardian 2: Email Address
Your answer
Who does student live with and what is the relationship to the student? *
Your answer
EMERGENCY CONTACT
Emergency Contact 1: Name (First Last) *
Your answer
Relationship to student *
Your answer
Phone Number *
Your answer
Emergency Contact 2: Name (First Last)
Your answer
Relationship to student
Your answer
Phone Number
Your answer
ADDITIONAL INFORMATION
Does the student have siblings? *
If yes, how many siblings?
Have the student been involved with the Juvenile Justice System?
If yes, please describe incident.
Your answer
MEDICAL HISTORY
Does your child have any serious medical problems (Asthma, Diabetes, Sickle Cell, etc.)? *
If yes, please list:
Your answer
Does your child have any mental health issues (ADD, ADHD, Bipolar, etc.)? *
If yes, please list:
Your answer
Does your child take any medications daily or routinely? *
If yes, please list:
Your answer
Does your child have any physical restrictions or limitations that will prevent them from participating in sports/dance/ running, etc.? *
If yes, please list:
Your answer
Does your child have any allergies to medicine or food? *
If yes, please list:
Your answer
When was your child's last physical exam? *
MM
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DD
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YYYY
Are your child's immunizations (shots) up to date? *
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