Mentee Registration Form

Registration Form

Fill out the form carefully for registration of your 7th or 8th grader for the Youth Connective peer mentoring SUMMER PROGRAM. Youth Connective is run by the Dedham Organization for Substance Awareness (DOSA) a community coalition that promotes awareness and healthy decision making with the goal of preventing youth substance misuse.
Student Name

First NameMiddle NameLast Name
Gender
Birth Date

MonthDayYear
Address

Street Address

CityState / Province

Postal / Zip Code
We aim to provide a great match between the Mentor and the Mentee. This enhances the experience and adds real value to the Mentee and the Mentor. To help us make this best match give us some idea of your interests, hobbies etc.
Is there anything else program staff should know about your child?
Parent/ Guardian Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/ Guardian Email
example@example.com
Please fill out below the emergency contact information for the child you are registering*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent or Guardian signature*
Student*
Should be Empty: