Lifeline For Kingz Enrollment Form
Complete this application to enroll your child in the Lifeline for Kingz 6-week mentorship program focused on leadership, life skills, and empowerment.
Participant Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
School Name
Grade Level
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parents or Guardians Full Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Full Name
Relationship To Youth
Phone Number
Please enter a valid phone number.
Does the youth have any allergies or medical conditions?
Yes
No
If Youth have a medical condition or allergies please explain
Are there any behavioral or special needs we should be aware of?
Are there any behavioral or special needs we should be aware of?
What do you hope your child will gain from this program?
Has your child ever participated in a mentorship program before?
Yes
No
How did you hear about Lifeline for Kingz?
Social Media
Website
Family/Friends
School
Flyer
Other
Do you give permission for your child to participate in all program activities?
Yes
No
Do you give consent for photos/videos of your child to be used for program promotion?
Yes
No
Parents or Guardians Signature
Date
-
Month
-
Day
Year
Date
Should be Empty: