First Name *

Last Name *

Father/Mother/Guardian *

Email *

Phone

Postal code *

Mentee Full Name *

Mentee Date of Birth *

Mentee Gender *

What topics do you think your child would be interested in learning about? *

Are you comfortable with your child participating in a one-on-one/group mentoring relationship with one or more mentors as well as one or more peers? *

In which specific area(s) would you like to see your child improve? *

What are your child's strengths? *

Are you able to attend the monthly parent calls? If not, why?. *

Is there anything else you want us to know about you or your child? *