Parent/Mentee Interest Form

Mentee Name *
Mentee Name
Date of Birth *
Date of Birth
Home Phone *
Home Phone
Work Phone *
Work Phone
Emergency Contact Phone Number *
Emergency Contact Phone Number
Is your child available to attend our program on the 2nd and 4th Saturday of each month?
Section
Name of Primary Care Physician: *
Name of Primary Care Physician:
Name of Primary Care Physician Phone No.: *
Name of Primary Care Physician Phone No.:
Medical Insurance Provider Phone No.: *
Medical Insurance Provider Phone No.:
Please read each of the following and sign below to confirm: *
Nondiscrimination Policy: Reality Check Mentoring Inc. does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, height, weight, physical or mental ability.
Nondiscrimination Policy: Reality Check Mentoring Inc. does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, height, weight, physical or mental ability.