Real Men Real Heroes - Community Based Mentoring
Participant enrollment form
Email address *
Name of Child *
Your answer
Grade *
Your answer
School Attending *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Home Address *
Your answer
Parent/Guardian Name *
Your answer
Cell Phone *
Your answer
Alternate phone
Your answer
Parent's Email Address *
Your answer
In case of emergency, contact name: *
Your answer
In case of emergency, contact relationship *
Your answer
In case of emergency, contact phone number *
Your answer
In case of emergency, second contact name
Your answer
In case of emergency, second contact relationship
Your answer
In case of emergency, second contact phone number
Your answer
Please tell us about your child; his victories, his challenges, his academics and what you would like us to help him with *
Your answer
Please list any food allergies, medical information (including regular taken or medicines they may have with them), personal information that staff/mentors may need to know. Note: Staff/mentors will not be responsible for dispensing medication.
Your answer
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