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Mentoring Intake Form

Parent and Guardian Information
This question requires a valid email address.
Child's Information
This question requires a valid date format of MM/DD/YYYY.
calendar
Does your child play or show interest in a sport(s)?  *This question is required.
If yes, what sport (s)?  *This question is required.
What are your child's hobbies and interests?  *This question is required.
Do you have a certain religious affiliation? (optional) 
If yes, what is your religion? (optional)
Does your child have learning differences? If so please indicate. *This question is required.
What are your child's academic interests? *This question is required.
Does your child have specific career aspirations that would be helpful in selecting a mentor?  *This question is required.
Does your child have allergies, asthma or other medical health concerns?  *This question is required.
Please rank the following answers based on importance. 
(1 being most important, 3 being least)

What is the most important goal for your mentored child?  *This question is required.
1-2-1 Mentoring is a fee based service. However, we do offer need based scholarships determined by income and need. Would you like a Scholarship Application emailed to you?  *This question is required.