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Peer Elementary Mentee Application

Welcome

This application is intended for the BHS Wednesday mentoring program from 3:30-4:30PM.
(To Be Completed by the Parent/Guardian)
Youth Information
This question requires a valid date format of MM/DD/YYYY.
calendar
Gender *This question is required.
Guardian Information
This question requires a valid email address.
Emergency Contact *This question is required.
Does your son/daughter have any physical problems or limitations? *This question is required.
Is your son/daughter currently receiving treatment for any medical issues? *This question is required.
Is he/she currently on any type of medications? *This question is required.
Does your son/daughter have any known allergies or adverse reactions to medications? *This question is required.
Does your son/daughter have any emotional issues or problems right now? *This question is required.