Oasis Mentoring Program Enrollment Form (2019-2020)
(To be completed by the Parent/Guardian)
Email address *
PERSONAL INFORMATION
*
YOUTH'S FIRST NAME: *
Your answer
YOUTH'S LAST NAME: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
AGE: *
Your answer
GENDER: *
ETHNICITY:
NAME OF SCHOOL: *
Your answer
GRADE: *
T-SHIRT SIZE ($15): *
PARENT/GUARDIAN NAME: *
Your answer
RELATIONSHIP TO YOUTH *
STREET ADDRESS: *
Your answer
CITY, STATE, ZIP: *
Your answer
PRIMARY PHONE NUMBER: *
Your answer
OTHER PHONE NUMBER:
Your answer
EMERGENCY CONTACT NAME: *
Your answer
EMERGENCY CONTACT NUMBER: *
Your answer
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