MEN OF PROOF Male Mentoring Program Registration & Waiver

MEN OF PROOF Male Mentoring Program Registration & Waiver

Building Stronger Boys. Creating Better Men.
Participant Information
Participant Full Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Gender
School Name
Grade Level
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Zip Code
Parent/Guardian Information
Parent/Guardian Full Name

First NameMiddle NameLast Name
Relationship to Participant
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Program Interest
Program Interest
Short Response Questions
Why are you interested in Men of Proof?
What are some goals you want to work on personally?
Is there anything you would like mentors to know about you?
Medical & Safety Information
Allergies
Medical Conditions
Current Medications
Special Accommodations Needed
Doctor Name
Doctor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Communication Opt-In
Text Message Opt-In
Email Opt-In
Signatures
Parent/Guardian Signature
Date

MonthDayYear
Date
Should be Empty: