Queens Esteem Kickoff/Intake Form

Mentorship Interest Form
Parent/Guardian Info
Name*

First NameLast Name
e-mail*
Cell Phone
Primary Phone*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact (If Parent/Guardian cannot be reached)*
Relationship to Student*
Emergency Phone*
Esteem Girl Info
Esteem Girl Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Grade in School 2022-2023
Esteem Girl email
Esteem Girl Cell Phone
Number of Years In Queens Esteem
New or Returning Mentee?*

Returning MenteeNew Mentee
Membership Location*

AtlantaTampa
What do you love most about yourself?
What is the one thing you'd like to improve about yourself?
Topics of Interest*
Add Esteem Girl 2?

Add Esteem Girl 2
Esteem Girl (2)Info
Esteem Girl Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Grade in School 2022-2023
Esteem Girl email
Esteem Girl Cell Phone
New or Returning Mentee?*

Returning MenteeNew Mentee
Number of Years in Queens Esteem
Membership Location

AtlantaTampa
What is the one thing you'd like to improve about yourself?
What do you love most about yourself?
Topics of Interest*
Kickoff Interest RSVP

Would you like to meet our Mentors and Learn More about the Program?
RSVP Email
Location*

Tampa 12/10Atlanta 12/17
# of Guests
For any questions please feel free to email us at queensesteem@gmail.com . Please be sure to follow us on

IG @esteemgirlstpa @esteemgirlsatl

Facebook at Queens Esteem Inc.
Notes:
Acknowlegements

The "fine print"
By checking I Agree below and submitting this form, you, the Parent or Guardian of the above student(s), agree to release Queens Esteem Inc., including instructors and assistants from liability for any and all injuries that may occur while in our care. You also give your permission for the public display of any studio visual images that your child may appear in.
Acknowlegement*

I Agree
Should be Empty:

Mentorship Interest Form

Parent/Guardian Info

Esteem Girl Info

Esteem Girl (2)Info

Kickoff Interest RSVP

Acknowlegements