Special Mentorship Program Registration

Special Mentorship Program Registration
CHILD INFORMATION:
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Name of School*
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
What are you looking for in this program?
What are your interests for the future?
Do you have any questions, comments or concerns?
Pay Now
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Special Mentorship Program $50.00
n order to attend this program, this form must be completed thoroughly, which includes the program fee of $50.

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