Parent/Guardian Interest Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City/State
*
Email
*
example@example.com
Preferred Method of Contact
*
Please Select
Text
Phone Call
Email
Occupation
*
Back
Next
Athlete's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Grade
*
Please Select
6th
7th
8th
9th
10th
11th
12th
Post Grad
School Name
*
Sport(s) Played
*
Primary Position(s)
Back
Next
Household Type
*
Please Select
Single-parent
Co-parenting
Blended family
Guardian led
Other
What areas of support do you feel your child needs most? (check all that apply)
*
Academic guidance
Emotional/mental wellness
Positive male role models
Accountability & discipline
Leadership training
Exposure opportunities
Athletic development
Social skills
Other
What goals do you have for your child academically, personally, or athletically?
*
What challenges are your child currently experiencing (if any)?
Can you commit to supporting your child in attending sessions, meetings, events, and program activities?
*
Please Select
Yes
No
I need more information
Would you like to attend a Parent Information Session?
*
Please Select
Yes
No
Maybe
Parent/Guardian Consent
*
I give permission for Rewrite The Play to contact me with program updates, enrollment information, and future opportunities.
Signature
*
Should be Empty: