Fellowship Application

I am

Full Name

First NameLast Name

Relationship or role?

Organization (if any)

Email

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Full Name

First NameLast Name

Email

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

First name and Last Initial

Age

Grade

City

State

Tell us a little about him and why the Fellowship could be a good fit.

0/100

What would you most like him to gain?

Days and times that work for weekly in-person sessions?

Will getting to sessions be a challenge?

Anything we should know so we can support him?

0/100

Would you be open to virtual sessions?

Agreement 1

Agreement 2

Agreement 3

Agreement 4

Your privacy

What we collect your contact details, relationship or role, and organization (if any); the young man's first name, age, grade, and city and county; his parent or guardian's contact details if you are nominating him; and your notes about fit, what you hope he gains, schedule, getting to sessions, and support. We don't ask for diagnoses, medical records, or school records.

Why to review applications and plan each group.

Who can see our Executive Director and our Clinical Director.

Shared? Not outside Holistic+Kin, except as our Privacy Policy describes. A parent or legal guardian must consent before he is enrolled.

Full details are in our Privacy Policy.

Please verify that you are human

Who is Submitting?

About You

His parent or guardian

About the young man

Agreements