The BU Collective Registration Form

1
Teen's Name
First Name
Last Name
2
Age
3
Date of Birth
Date
Month
Day
Year
4
Phone NumberMentees Number
Area Code
Phone Number
5
Email AddressMentees email. If they do not have an email put N/A
example@example.com
6
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
School
8
Grade Level
9
Languages spoken other than English?If English is not their primary language please state here.
10
Why do you want/need a mentor?Share what you hope to get out of learning in a shared space with other young women your age.
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Small
Ok
Ok
11
Tell us about the your personality and strengths
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Small
Ok
Ok
12
What would your friends and family say are some of the your challenges?These are things you struggle with that people have brought to your attention or that you are aware of.
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Ok
Ok
13
Is there anything you would like us to be aware of?Anything you need to feel seen and heard in our meeting spaces? This could be triggers, a name you'd like to be called, or anything else you can think of.
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Ok
14
List some of the goals/changes the you would like to achieve while in this program. This could either be academic, social, and personal skills, cultural connection, professional development, networking, communication skills, leadership skills, or other skills.Also feel free to share any ideas of things you'd like to do together,.
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15
Name
First Name
Last Name
16
Phone Number
Area Code
Phone Number
17
Relationship
18
Additional Parent/Guardian Information
19
Languages spoken other than English?If English is not you primary language please state here.
20
Emergency Contacts
Name
Number
Relationship
Emergency 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Emergency 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Emergency 1
Emergency 2
Name
Row 0, Column 0
Number
Row 0, Column 1
Relationship
Row 0, Column 2
Name
Row 1, Column 0
Number
Row 1, Column 1
Relationship
Row 1, Column 2
1 of 2
21
Insurance Provider Name
22
Medical Insurance #
23
Does the child have any medical conditions or medications that we should be aware of?If yes, please describe
24
Does the child have any allergies?If yes, please describe
25
Does the youth have any emotional, mental, physical, or specific medical health conditions that we should know about?If yes, please describe
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Ok
Ok
26
I agree to follow the guidelines, rules, and policies of the organization.

If a chaperone or driver is needed, I'll do that.

I allow my child to be photographed or be part of the video that will be used for marketing, promotion, and advertisements.

The repeated offense of the youth may result in suspension or expulsion.

Parent/Guardian registered in this form has legal custody over the child.

I allow my child to ride any vehicle that is related to the group's activities provided that there's an adult on board.

For medical emergencies, I allow the medical team of this organization to take care of my child.

I release this organization from any and all liability from accident or injury to the child during the organization related events.
27
Terms and Conditions* This field is required.
28
Parent/Guardian Signature
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29
Date Signed
Date
Month
Day
Year
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