Confirmation registration
Student Information
Student's Full Name*
Student Cell Phone
School Grade*
School*

Birthdate*
Student Mailing Address*
Random Fact About the Student
Mentor Information
Mentors will be asked to attend class with the student. This is an hour and a half commitment almost every Sunday. Please remember that a mentor must be at least 4 years older than the student AND the mentor cannot be a parent/guardian.
Does the Student Have a Mentor?*
Do you need help finding a mentor for your student?
If you have your mentor please give us their information.
Mentor Name
Mentor Phone Number
Mentor Mailing Address
Mentor's E-mail
What is the mentor's relation to the student?
Parent/Guardian Information
Student's Primary Household
Relation to Student
Name(s)*
Primary Number*
Number to Receive Text Messages
E-Mail*
Mailing Address (if different from student)
Street Address (including city)*
Secondary Household Information: Is there anyone we should be sending additional information to?
Relation to Student
Name(s)
Phone Number
E-Mail
Mailing Address