Flowers That Bloom Mentoring Inc. Application
MENTEE INFORMATION
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Ethnicity
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Preferred Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
EMERGENCY CONTACT & MEDICAL INFORMATION
Emergency Person
*
Phone Number
*
Does your child have any food allergies? If so, please specify.
*
Please list all medications if any.
*
PICK UP SAFETY
Names of individuals that can pick up your child. (They must show identification. The name on ID must match the name on this application or your child will not be able to leave. This is for the safety of your child. NO EXCEPTIONS.)
Pick up Person #1
*
First Name
Last Name
Pick up Person #2
First Name
Last Name
Pick up Person #3
First Name
Last Name
Pick up Person #4
First Name
Last Name
Please answer the following questions to the best of your ability.
How did you find out about the program?
*
What motivated you to apply to the program?
*
What are your hobbies, special skills, or other interest?
*
What do you like to do in your free time?
*
What do you hope to gain from Flowers That Bloom Mentoring Inc.?
*
PARENTS
What do you hope your mentee gains from the program?
*
Has your mentee ever been in a mentoring organization?
*
Yes
No
If yes, please explain.
SIGNATURES
I certify that the information I have provided is correct to the best of my knowledge. I (both Parent and Mentee) will follow all rules and regulations of the program.
Parent Signature
*
Signature Date
*
-
Month
-
Day
Year
Date
Mentee Signature
*
Signature Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: