H.Y.P.E Mentorship Program
Sign Up For Our Program
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Name
First Name
Last Name
Age
Date Of Birth
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Year
Date
Gender
Telephone Number
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Email
example@example.com
Permanent Address
Street Address
Street Address Line 2
City
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Ethnicity
American Indian or Alaska Native
White
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Languages Spoken
Parents household Status
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If married, what is the name of your spouse?
First Name
Last Name
Do you have other children?
Yes
No
How many children live in the home?
Upload a birth certificate or school record
Browse Files
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of
Areas you see the struggle
Why do you want your child to be mentored by our program?
What are the qualities and abilities do you feel like they need work on?
What are your childs goals and ambitions?
Add anything else you feel will be helpful in getting to know your child?
Parent Signature
Child/ Teenager Signature
Date Signed
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Year
Date
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