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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
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