Child / Youth Information
Child’s Full Name
*
Child Gender
*
Male
Female
Date of Birth
*
/
Month
/
Day
Year
Date
School Attending
*
Parent / Guardian Full Name
*
Relationship to Child
*
Phone Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Home Address
*
Zip Code
*
Allergies, medical conditions, or special needs:
*
Emergency Contact Name
*
Emergency Contact Phone #
*
Format: (000) 000-0000.
Mentorship Information
What are you hoping your child gains from mentorship through H.Y.P.E.?
*
I give permission for my child’s photo/video to be used by H.Y.P.E. for program-related purposes.
*
YES
NO
Other Details You’d Like to Add
Helping Young People Elevate (H.Y.P.E
Founder: Cordell Walker Sr.
Email: h.y.p.elevate@gmail.com
Submit
Should be Empty: