Mothers Name
First Name
Last Name
Mothers Date of Birth
-
Month
-
Day
Year
Date
Daughters Name
First Name
Last Name
Daughters Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred method of contact?
Email
Text
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ethnicity (Mother)
Ethnicity (Daughter)
Languages spoken (Mother)
Languages spoken (Daughter)
Marital Status
Please Selecti
Single
Engaged
Married
Divorced
Widowed
Company Name
What is your profession?
Job Position/Title
Do you have transportation to attend the monthy sessions?
Yes
No
How did you hear about the B.A.G.S. mentoring program powered by The Chosen Ones, Inc.
Facebook
Instagram
Nextdoor
TC1S.org Website
Other
What are your hobbies and interests (mother)?
What are your daughters hobbies and interests?
What activities do you and your daughter enjoy doing together?
What is your love language (Mother)?
Quality Time
Physical Touch
Words of Affirmation
Acts of Service
Gifts
Unknown
What is your daughters love language?
Quality Time
Physical Touch
Words of Affirmation
Acts of Service
Gifts
Unknown
What challenges are you and your daughter facing or have faced in your mother - daughter relationship?
How would you describe your mother-daughter dynamic?
What are some of your goals as mother and daughter ?
Mentoring Information
What are you hoping to gain by participating in the mentoring program?
What specific areas would you like support or growth in? (Check all that apply)
Communication Skills
Strengthening Mother-Daughter Bond
Self-Esteem and Confidence
Conflict resolution
Other
If you selected "other" for the specific area(s) you would like support or growth in, please use the space below to explain.
Are you open to ongoing communication and check-ins from program leaders and/or assigned mentor?
Hours only
How many hours per month are you and your daughter available to participate in the program?
Hours only
Are you and your daughter able to meet in-person once a month for 12 months?
Yes
No
In addition to meeting in person once a month, are you and your daughter able to meet virtually once a month for 12 months?
Yes
No
Are you and your daughter able to attend the first session being held on August 16, 2025 in Stonecrest GA?
Yes
No
Agreement
Photography Consent: As part of our mentorship program, we often capture moments and events through photographs to showcase the positive impact of mentorship. We would like to seek your consent regarding the use of your photographs in promotional materials, social media, and other related platforms.Your choice regarding photography consent will be respected, and it will not affect your participation in the mentorship program. If you have any questions or concerns, please feel free to contact us.
I give consent for photographs of me and of my minor daughter to be used in promotional materials, social media, and related platforms for the purpose of highlighting the mentorship program
I do not give consent for photographs of me or my daughter to be used in promotional materials, social media, and related platforms.
Liability Waiver I understand and accept that participation in the B.A.G.S. program may involve physical activity and group interaction. I release The Chosen Ones, Inc., its staff, volunteers, and affiliates from any liability for injuries or incidents that may occur.
Yes
No
Code of Conduct Agreement I agree to engage respectfully, arrive on time, participate actively, and support a safe, positive environment. I understand that disruptive or harmful behavior may result in dismissal from the program.
Yes
No
Confidentiality Agreement I agree to maintain the confidentiality of any personal information shared by others in the program and expect the same in return.
Yes
No
Mother Signature
Daughter Acknowledgement
Date Signed
-
Month
-
Day
Year
Date
Print
Submit
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