Membership

MEMBERSHIP APPLICATION

APPLICANT INFORMATION

* Indicates required field

Name *

First

Last

Phone Number *

Date of Birth (MM/DD/YYYY) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

PARENT CONTACT INFORMATION

Name *

First

Last

Phone Number *

Email *

Fax *

Address *

Line 1

Line 2

City

State

Zip Code

Country

EMERGENCY CONTACT

Name of a relative not residing with you: *

First

Last

Relationship: *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

SCHOOL INFORMATION

School: *

Current Grade: *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Do you consent to mentor seeing student during school hours? *

Yes No

MENTOR REQUEST

1st Choice Name: *

2nd Choice Name: *

3rd Choice Name: *

Upload Photo Waiver *

Max file size: 20MB

SIGNATURES

I authorize permission for my child(ren) to participate in this program. By signing and submitting this application; I consent to my child being transported by mentors of this organization. I also consent to my child being photographed during participation, events and outings. I understand that this membership will expire in one year of submission of application and fee, and must be renewed annually. *

First

Last

Date: (MM/DD/YYYY) *

Signature of Parent: *

First

Last

Date: (MM/DD/YYYY) *

Submit