'22-'23 "It's A 'We' Thing" Mentorship Program Registration Form

'22-'23 "It's A 'We' Thing" Mentorship Program Registration Form

Thank you for showing interest in our program! Please answer all of the questions to the best of your ability. This form will help gather important information, learn more about your child, and create a match for your child's mentor. Please ensure that your child completes the personal questions (at the end) as it relates to MTD. If you are registering for more than one child, please complete a separate form for each child. Please dedicate 10-15 minutes to complete. You must complete this form in one sitting; you will be unable to exit out and come back.
PROGRAM REQUIREMENTS

- Must identify as a Black (African American) girl, between the ages of 13 -18

- Must complete the program registration form and submit payment

- Must be willing to commit to AT LEAST (2-3) program days out of the month (Tuesdays & Saturdays). Exact dates will be provided.

- Parent/Guardian MUST watch Recap video to receive important updates to this year's program.

PARENT INFO MEETING RECAP VIDEO

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VALUE OF PROGRAM

- Includes YMCA Membership

- Fun Trips & Guest Speakers

- Personalized Action Plan for your child (personal & professional)

- One-on-One mentorship

- Parent Workshops

- Meals

- MTD Swag Bag

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COST OF PROGRAM: $350 (Oct-May)

Payment Plan Options:

- (1) payment of $350 (Due on 10/11)

- (2) installments of $175 (Due on 10/11 & 12/11)

- (3) installments of $116.66 (Due on 10/11, 11/11, & 12/11)

(Limited Partial Scholarships Available - see link below)

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DETAILS

Program Registration Deadline: Tuesday, October 11, 2022

Payment Options:

- Paypal: www.Paypal.me/mtdistinction (you can also click the "donate" button on our website)

- Debit or Credit

- Check: Payable to Make the Distinction

**If your child is applying for the scholarship, please do not submit payment until they receive an acceptance letter. **

First Day of Program: Tuesday, Oct 25 @ 6-8pm (Columbia North YMCA)

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CONTACT

Website: www.makethedistinction.org

Email: contact@makethedistinction.org

IMPORTANT LINKS

Apply Here: MTD Scholarship Application
Child Full Name*

First NameLast Name
Home Address*
Date of Birth*

MonthDayYear
Date
Age*
Name of Current School*
Grade*
Child's Cell Phone Number
Child's Email Address

Parent/Guardian Full Name *

First NameLast Name
Home Address (if same as child, leave blank)
Guardian's Relationship to Child *
Guardian's Email Address (please provide an email that you check often)*
Guardian's Cell Phone Number*

Emergency Contact Name & Phone Number*
List child's allergies and/or dietary restrictions*
List any medications that we should be aware of *
Additional information
Why do you want to join Make the Distinction? (please answer question in 3-4 sentences)*
Describe (2) personal challenges that you are experiencing as a teen girl. If you cannot think of any, put yourself in another teen girl's shoes and imagine what your peers might experience. (please answer question in 3-4 sentences)*
List (3-5) hobbies and interests (this will help find a good match for your mentor)*
Please describe your ideal mentor. (think about personality, interests, professional background, etc)*
Please describe your personality in a few words.*
How can MTD benefit from your participation? (please answer in 3-4 sentences)*
List (3) career/entrepreneurial interests*
MEDIA CONSENT I authorize Make The Distinction to use and publish the media in print and/or electronically. I agree that Make The Distinction may use such media of my child with or without their name and for any social media, publicity, advertising, and web content purposes. Having the ability to take pictures, videos, and other media are essential to the growth and development of our program. Make The Distinction will ensure that all pictures and videos taken of participants will be used for the development and promotion of Make The Distinction. All media will be handled responsibly and with discretion. By typing "YES", you understand and agree to the photo and video release terms.*
Please provide additional information about yourself that would be helpful to the MTD team.

Please sign below to confirm completion and submission of this registration form.
Child Signature*

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Parent Signature*

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Should be Empty: