Cultivating Justice: A Community Garden Initiative of Media Fellowship House

Parent/Guardian Information

Please complete this section if under the age of 18.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email*
example@example.com
What is/are the best way(s) to get in touch with parent/guardian?*

TextPhonecallEmailOther
What’s the best day(s) and time to reach you?

Mentor Information

Please identify a teacher, mentor, or family member who can tell us why you'd be a great fit for this youth leadership program at Media Fellowship House! We'll reach out to them to learn more.
Mentor Name

First NameLast Name
Mentor's Email
example@example.com
Mentor's Phone
Please enter a valid phone number.
What is this mentor's relationship to you?
Example: Teacher, Youth Leader, Counselor, Family Member