Virtuous Steps Girls Mentoring Application

Virtuous Steps Girls Mentoring Application - Register for Orientation - Sept. 26 @ 1 PM

Virtuous Steps Girls Mentoring Program will host an Orientation for teens and parents on Sunday, September 26th at 1 PM. The mentorship program teaches life skills, self-esteem and much more to teen girls 11 to 18 years old. Virtual Steps is open to the public and the orientation will be virtually via Zoom, so tell your friends and family about it. **NOTE: Virtual Steps Girls Mentoring Program is a program administered by Liberty Community Development Corp (www.lcdcorp.og). There is an investment / program registration fee of $20 per youth that will be due after the orientation session is held.
YOUTH / TEEN INFO
Youth's Name *

First Name Last Name
Youth's email *
Youth's Cell Number *
Please enter your best contact number
Birthdate (MM/DD) *
example: Enter June 24 as 06/24
Youth's Age *
Select current age
Name of School Youth Attends *
Current Grade *
Select current grade as or Sept. 2021
PARENT INFO
Parent / Guardian Name *

First Name Last Name
Relationship to Youth *
Please select one
Parent / Guardian Email *
Parent / Guardian Cell Number *
Please enter your best contact number
Address *

Street Address

Street Address Line 2 (enter Apt / Unit #)

City State / Province

Postal / Zip Code
** EMERGENCY CONTACT & PHONE NUMBER *
i.e. Joan Smith, 443-444-1212
APPLICATION QUESTIONS

Please answer all of the following questions as completely as possible. The answers to these questions will aid us in the mentor matching process.
1. Why do you/your child want to participate in a mentoring program? *
2. Is your child available to meet with a mentor a minimum of one hour per week via phone and the Qooper App (mentoring software platform)? *
3. Is your child available to meet from 12:30 PM - 1:30 PM for our sessions on the 2nd and 4th Sunday of each month? * *
4. Is your child available to attend a minimum of three Virtual Town Halls? *
5. Please explain any particular scheduling issues that you may have, if applicable.
By submitting this form, you agree to the following:
- I give my informed consent and permission for my child to participate in the Virtuous Steps Mentoring Program and its related activities.
- I agree to have my child follow all of the mentoring program guidelines and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship.
Parent's Signature *

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Virtuous Steps Girls Mentoring Application - Register for Orientation - Sept. 26 @ 1 PM

YOUTH / TEEN INFO

PARENT INFO

APPLICATION QUESTIONS