Youth Programs Sign Up

1
How did you hear about us?* This field is required.
Please Select
Please Select
Word of Mouth
Social Media
Google
Timoteo
Other
2
Please specify how you heard about us.
3
Youth's Name* This field is required.
First Name
Last Name
4
Youth's Birth Date* This field is required. Please enter the youth's birthday
Month
Day
Year
5
What grade is {youthsName} in?* This field is required.
Please Select
Please Select
6th
7th
8th
9th
10th
11th
12th
6
Which school does {youthsName} attend? * This field is required.
7
Youth Phone Number
Please enter a valid phone number.
8
Youth Home Zip code* This field is required.Please enter the zip code for youth's primary residence
9
Your relationship to {youthsName}?* This field is required.
Please Select
Please Select
Self
Parent/Guardian
School Counselor/Teacher
Social Worker/Similar
Timoteo Staff
Other
10
Would you like to add any Parent/Guardian information:
Yes
No
11
Parent/Guardian Name
First Name
Last Name
12
Parent/Guardian Phone Number
Please enter a valid phone number.
13
Parent/Guardian Email
example@example.com
14
Program selection:* This field is required.Choose all the opportunities you're interested in. If you would like to view a complete description of our youth mentoring programs please click here or feel free to visit our website.
Leadership Development/Mentoring (Inspire)
College/Career Prep (Inspire)
Skills Development - Photography (Pathways)
Tutoring (Math and Reading Focus)
15
Name 2 goals you have for {youthsName}* This field is required.
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Large
Normal
Small
Ok
Ok
16
Is there anything you'd like to add?If you’re adding additional young people, who live in this household, please provide their full name and birth date.
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Normal
Small
Ok
Ok
Should be Empty: