Cultivating Youth Mentee Interest Form
Thank you for your interest in Cultivating Youth. Although we have limited space, your application is welcome and will be considered carefully. Our Spring Program will begin February 19, 2024. 
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Email *
How old is the youth? (Our program serves ages 8-18 years old)
 *
Youth's First and Last Name *
Youth's gender? *
Youth's physical address? *
Youth's Date of Birth
 *
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What school does youth attend? *
What grade is the youth in currently? (If it is summer, next school year.) *
Youth must be able to commit at least two days per week to remain active. Can this youth commit? *
Parent/Guardian First and Last Name?
 *
Parent/Guardian Cell Phone Number?
 *
Parent/Guardian Email Address?
Parent/Guardian Street Address?
 *
What areas can youth use some improvement or needs assistance? *
Required
Please explain in more details about the area of improvement or help needed in more details. *
What is the youth's race? *
Are there are specialized services that the youth participate in currently? (Therapy/counseling, speech, etc)  *
How did you hear about Cultivating Youth? 
 *
Any additional information we may need to know? *
*
Required
By typing your name below, you acknowledge that you have read, understand and agree to all the terms and conditions outlined in this agreement. Please type your name below. *
Today's Date
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A copy of your responses will be emailed to the address you provided.
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