LeadUS Mentoring Program 2015-16

WIBCA's Maasai Mentoring Group

Mentorship sessions will be held online via Zoom.

(*Changes may apply pending provincial regulations*)

This program is FREE with limited space and requires a commitment to participate for 1 year.

For more information please contact:

admin@wibca.org or call at (514) 683-3925

Participant's Information
Full Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Mobile Number *

Area Code Phone Number
E-mail *
Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Availability for the program
Day of availability:

Wednesday(s) Thursday(s) Friday(s)
Would you be interested in Saturday(s)

Yes No
Other Hobbies/ Interests
Activities you're already enrolled in

Family Information
Guardian Full Name
Phone Number

Area Code Phone Number
Email Address
Emergency Contact's Name *
Emergency Contact Phone Number *

Area Code Phone Number
Relationship to Emergency Contact's *

Submission
Is there any other information that you would like to share with us?
Should be Empty: