Student Name *

First Name

Last Name

Student Date of Birth *

MM

DD

YYYY

Student Signature *

First Name

Last Name

Student Phone

(###)

###

####

Student Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Ethnicity/Race

Optional. For us to better understand our students background and for grant writing purposes we ask that you share your Ethnicity/Race.

Hispanic or Latino

Not Hispanic or Latino

Black or African American

White

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Multi-Racial

Parent / Guardian Name *

First Name

Last Name

Parent / Guardian Phone

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Consent

Photo Consent - I approve of Endless Opportunities taking photos of my students during meeting and special events for program promotional materials only.

Transportation Consent - I approve of Endless Opportunities to transport my student to and from meetings and special events.

Parent Signature *

I agree by typing my name that all the above information is accurate and completed to the best of my ability. I hereby, allow Endless Opportunities to speak, meet, and mentor my student moving forward. I am aware that there will be additional information required for me to complete before full acceptance into mentoring program.

First Name

Last Name

Today's Date *

MM

DD

YYYY