Child Enrollment Application for High School Mentoring

If you are the parent or guardian of a child in grades 8-12 and would like your child to participate in the LSS High School Mentoring program, please complete the fields listed below and click "Send Now" at the bottom of the page. If you would like to enroll more than one child, please complete a form for each person. Printed enrollment forms are available upon request.

If you do not receive a confirmation email within 48 hours confirming the application went through successfully, please contact LSS USucceed at 605-444-7803.

Fill Out the Application to Enroll Your Child in High School Mentoring

Contact Information

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

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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

Emergency contact name

Relationship

Phone

Matching Information

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.)

By signing, you understand that you hold your child's school district, its schools and staff, and Lutheran Social Services of South Dakota, its staff and mentors, free of liability in the event of any results or developments occurring as part of their efforts on your behalf or the behalf of your son/daughter/guardian student. Thank you!

Typed Parent/Guardian Signature

Date