Child Enrollment Application | Community

Parent First Name

Parent Last Name

Child First Name

Child Last Name

Child Birth Date

Child Gender (identifies as):

male
female

Child Home Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Parent Home Phone

Parent Cell Phone

Parent Email

Preferred contact method:

Phone call
Text
Email

Child School

Child Grade Level

Child Primary Language

Does the child spend significant time at a different residence

yes
no

If yes, please indicate who with and the relationship

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If yes, please indicate the address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

If the child is male, are they willing to be matched with a female volunteer?

yes
no

How did you become aware of this program? Check as many as apply and describe below

Please provide any additional referral details

Emergency contact name

Relationship

Phone

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Please list any other information about your child you feel would be helpful in matching them. This can include any special hobbies, talents, or interests.

Please describe a few things your child would like to do when participating in this program.

Why are you interested in this program for your child?

Any issues of concern to note (family history, physical/mental health issues, health conditions)?

What other community programs is your child involved with? (sports, clubs, lessons, after-school programs, church, etc.)

Community Mentoring Enrollment Application

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Referral Information

Matching Information