MENTEE APPLICATION

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Student Section:
Last Name:* First Name:
Student Number:* School : *  
Grade:* Gender:
Ethnicity:*
Birth Date:*
T-Shirt Size:
Student Phone (xxx-xxx-xxxx):
(Best # to reach you)*
Student Email:
Home Address:*
City:* State:*
Zip:*


Parent Section:
First Name:* Last Name:*
Parent Phone (xxx-xxx-xxxx):* Parent Email:*


Does your child receive any additional education support services (Early Intervention/EIP, Special Education, Gifted, etc.)?*

Agreement Section:

Mentee (Student) (Please read and select all boxes)*

Parent (Please read and select all boxes)*

Give permission to my child's mentor to transport my child outside of the school campus * :

I understand that I am required to attend a minimum of two events during the school year. (Please initial below)*

I understand that entering my first and last name below represents my electronic signature to this application. (Parent)*

I understand that entering my first and last name below represents my electronic signature to this application. (Student)*