Youth Mentoring Registration Form

Youth Mentoring Registration Form

Fill out the form carefully for registration. Youth Mentoring-CCDN has 2 youth mentoring programs. Precious Pearls of Promise (11-18 young ladies) and Diamonds in the Rough (11-18 young men). Mentees meet 1st and 3rd Saturdays 9:00 AM-2:00 PM.
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student E-mail
Mobile Number

Area CodePhone Number
Home Number

Area CodePhone Number
Program of Interest (Check All that Apply)

Precious Pearls of Promise (Youth Mentoring for young ladies ages 11-18)Diamonds in the Rough (Youth Mentoring for young men ages 11-18)Family Mentoring SessionsOne to One Life Development Mentoring SessionsInspire Youth Development (Soft Skills job training ages 17-25)High School and College Academic AdvisingDrop-out Recovery or GED Preparation
Questions or Additional Comments
Guardianship
Parent or Legal Guardian Information

First NameLast Name
Cell Phone (Parent or Legal Guardian)

Area CodePhone Number
Home Number (Parent or Legal Guardian

Area CodePhone Number

Emergency Persons/Emergency Contacts/Medical Information
PICK UP: Person with permission to pick up youth other than parents:

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
EMERGENCY CONTACT

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
In case of emergency do we have permission to obtain medical attention for you/youth.

YesNo
NOTE: Please be advised that CCDN will require a copy of the insurance card on file for emergency purposes.
Are there any medical conditions CCDN need to be aware of?

YesNo
Please explain here:

Education and Behavioral Analysis