DreamJourney Virtual Mentoring Inquiry Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Are you interested in enrolling your student in the U.S. Dream Academy's Virtual Mentoring Program? Would you like to learn more about the program? Take a moment to complete the form below and a member of our team will follow up to provide more details.

Note that a Google sign-in is NOT required to complete this form, only if you want to save your progress.

How did you hear about U.S. Dream Academy's Virtual Mentoring Program? *

Event hosted by Angel Tree, Prison Fellowship, or Local Church

Family/Friend Referral

Google Search that led me to U.S. Dream Academy website

Global Leadership Academy -Philadelphia

Arizona GO Project

Recruitment event in Washington D.C.

Other:

Your Name (first and last) *

Phone Number (xxx-xxx-xxxx) *

Email Address *

Preferred Method of Contact *

Phone

Please list the name (first and last) and grade level of each student you are seeking to enroll in the Virtual Mentoring Program along with the name of their school. *

Please select your relationship to the student(s) listed above. (select all that apply) *

Parent

Legal Guardian

Sibling

Family Friend

Relative other than parent/sibling

Required

What is the best time of day to contact you? (select all that apply) *

Morning (10am-12pm)

Afternoon (1pm-3pm)

Late Afternoon (3pm-5pm)

Evening (5pm-7pm)

Required

Do any of your students have a parent/guardian that is currently incarcerated or that has been incarcerated in the past? *

Yes

Do any of your students have any other family member that is currently incarcerated or that has been incarcerated in the past? *

Yes

Please list the city and zip code where you are located. *

Does your student have access to a laptop or computer that can be used weekly to log on to a virtual mentoring session? *

Yes. My student has a laptop or computer to use for virtual mentoring sessions

No. My student would need to be provided a laptop or computer to use for virtual mentoring sessions

I have multiple students I would like to enroll in the program but they all share one laptop or computer.

Please provide any additional information that you believe will assist us in getting your student connected to the U.S. Dream Academy Virtual Mentoring Program.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of U.S. Dream Academy. Report Abuse

Forms