Youth Empowerment Collective Inquiry Form

Inquiry Form

Mentor (Grade 6th-9th) Coaching (Grade 10th-Post High School)
Positive Impact Empowerment (Females) Bro Code (Males)
Scholar Information
Scholar Name*

First NameLast Name
Scholar Mobile Number
Scholar E-mail *

Confirmation Email
School*
Grade/ Education Level*

6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeFreshman (College)First Year Trade SchoolOther
Parent/ Guardian Information
Parent/ Guardian Name*

First NameLast Name
Email*

Confirmation Emailexample@example.com
Phone Number*

Area CodePhone Number
Please list any challenges or concerns for your scholar academically*
Please list any challenges or concerns for your scholar at home*
How would you like to be contacted?

Phone (Call)Phone (TextEmail
I give The Youth Empowerment Collective permission to contact my child's school for school based referral information

YESNO
Next Steps:

Please allow 48 hours for us to respond to your inquiry. Within that time you receive an email with your registration packet. Also, there will be a link to schedule your in-take meeting.
Should be Empty:

Inquiry Form