LeadUS Mentoring Program 2015-16

WIBCA's Maasai Mentoring Group

Mentorship sessions are in-person on Saturday's.

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 NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Mobile Number*

Area CodePhone Number
E-mail*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Availability for the program
Day of availability:

Saturday(s)
Other Hobbies/ Interests
Specify activities already enrolled in

Family Information
Guardian Full Name
Phone Number

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

Area CodePhone Number
Relationship to Emergency Contact's*
Will you ensure dropoff and pickup on Saturday(s)

YesNo

Submission
PHOTO & VIDEO NOTICE:

Upon submitting this form you authorize WIBCA to use these images and videos for promotional purposes, including but not limited to:

✔ Social media (Facebook, Instagram, website, etc.)

✔ Printed materials (brochures, flyers, posters, etc.)

✔ Media and publicity (news articles, newsletters, etc.)

✔ Other marketing materials related to WIBCA activities.
Is there any other information that you would like to share with us?
Should be Empty: