Child Enrollment Application | Community

Parent First Name (Required)

Parent Last Name (Required)

Child First Name (Required)

Child Last Name (Required)

Child Birth Date (Required)

Child Gender

male
female

Child Home Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Parent Home Phone

Parent Cell Phone (Required)

Parent Email (Required)

Preferred contact method:

Phone call
Text
Email

Child School (Required)

Child Grade Level (Required)

Child Primary Language (Required)

Does the child spend significant time at a different residence

yes
no

If yes, please indicate who with and the relationship

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 LSS Climb Program? Check as many as apply and describe below

Please provide any additional referral details

Emergency contact name

Relationship

Phone

Sunday

Monday

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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? (sports, clubs, lessons, after-school programs, church, etc.)

Child Enrollment Application for Community Mentoring

Fill Out the Application To Enroll Your Child in Community Mentoring

Contact Information

Referral Information

Matching Information

Administration