Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What school do you attend?
*
School Email
*
example@example.com
What year are you in school?
*
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
Other
If other, specify
*
Personal Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who lives in the house with you?
*
How do you prefer to be contacted
*
Text
Email
Are you currently pregnant
*
Yes
No
If yes, what is your due date?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please tell us the name, sex and age of your baby?
*
What classes are you enrolled in?
*
What are your special interests, skills or talents?
*
Which extracurricular activities are you involved in?
*
What is your future career choice?
*
Are you currently employed?
*
Yes
No
If yes, where and how many hours?
*
What are your current needs?
*
For example: diapers, baby wipes, children's books, time management skills, etc.
What is the name of your doctor or clinic
*
What hospital provides you services
*
You are required to meet with your Mentor at least one hour er month for this program. Please specify the best times that you are available.
*
For example: Weekdays
Is the Father of the baby interested in being part of a mentorship program for dads?
*
Yes
No
Not sure
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