Youth Enrollment Form
Thank you for your interest in Southeast Ohio Youth Mentoring! Please complete the following form to help us match your child with the best mentoring program.
Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Contact Method
Call
Text
Email
Youth Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
School
Which SEOYM program(s) are you interested in? (check all that apply)
Community Mentoring
Youth in Leadership
CLI:MB
Bobcats & Buddies
East Before/After Care
Not Sure
By submitting this form, I acknowledge that I am the legal parent or guardian of the child named above or have been authorized by such and consent to SEOYM contacting me for program enrollment and participation.
I do NOT want to receive occasional updates and newsletters from SEOYM
Submit
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