Mentoring Group Registration

ImpACT Mentoring Program (Group Registration)

Complete the form below to sign up for our mentoring program
Group Name*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Group Leader Name*

First NameLast Name
E-mail*
Phone Number:*

Area CodePhone Number
Where did you hear about us?*

A Friend or colleaugeGoogleBlog PostSocial MediaOther
Group Information
Number of Youth Females*
(If none, type 0)
Number of Youth Males*
(if none, type 0)
Age range of youth*
Do youth have computer access?*

YesNo
Have your group been mentored by Empowered U previously*

YesNo
What are you looking for your group to gain from this mentoring program?*
Membership Rules
1. Membership is available to anyone 9 years of age or older but must be approved by parent/guardian below the age of 18.
2. You promise NOT to use to conduct any fraudulent or business activity or have more than one Member Account at any time.
3. Please send list of youth names to info@empowered-u.org
I have read, understood, and accepted the rules for membership.
Once you submit your application, we will contact you shortly to complete your membership application.

Thank you!
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ImpACT Mentoring Program (Group Registration)