JUDA Enrollment Form

Name

First NameLast Name
Email*
example@example.com
Cell Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
School*
Current Grade*
What is your preferred method of communication?*

TextEmailOther
Please upload a headshot of yourself*

Browse Files

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What are your best qualities?*
What career fields are you interested in?*
What are your hobbies?*
What volunteer work have you participated in this past year?*
What are you truly passionate about?*
Where do you see yourself in 20 years?*
Have you created a list of goals to accomplish in order to achieve that?*
What role do you think a mentor could play in your life?*
Are you hoping to establish a long term relationship with your mentor or do you prefer to take things one day at a time?*

Credit Card Information

Tuition$500.00CAD

Quantity

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

Province

Postal Code

Country