G-CODE Mentee Application

G-CODE

Mentee Application
Phone
Email
example@example.com
G-CODE
Youths Name
Grade
Birthday
Child’s Gender

MaleFemale
Child’s Ethnicity/Race

African AmericanCaucasianHispanicHatianAsianOther
School
School Contact
Parent or Guardian Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Home or Cell Phone
Email
example@example.com
Does Your Child Have Any Disabilities?

YesNo
Household:

Single Parent HouseholdTwo Parent Household
Number of Siblings:
Emergency Contact
Name
Relationship
Phone
Email
example@example.com
Please Read & Check Off Below Guidelines.

I grant permission and consent for my child to participate in G-CODE and its related activities, including weekly group meetings and periodic meetings with their assigned mentor.I grant permission for the school to share the academic progress of my child with his/her mentor.I grant permission for the school to share behavioral progress of my child with his/her mentor.I grant permission to use photographs of my child in print or online materials designed for news, informational or educational purposes related to G-CODE.I grant permission for my child to be transported via car by their mentor/G-CODE staff to and from meetings and activities.
I have reviewed the program guidelines with my child.
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the terms and conditions as outlined in the Guide for Parents and Guardians.
Parent / Guardian Signature

Clear
Should be Empty:

G-CODE

G-CODE

Emergency Contact