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Rogue Valley Mentoring After School Program Signup Form
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Preferred Name
Your answer
Gender
*
Choose
Male
Female
Other
If you said Other please explain
Your answer
Pronouns
He/Him
She/Her
They/Them/Theirs
Other:
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If you selected
Other
, please specify
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Street Address
*
Your answer
Apt/Suite
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Youth Phone number
*
Your answer
Type
*
Cell /Mobile
Home
May we text this number with info and updates while youth is enrolled?
*
Yes
No
Race *
Check all that apply
*
African
American Indian/Alaskan Native
Asian
Black
Middle Eastern
Native Hawaiian/Pacific Islander
Hispanic/Latino
Slavic
Unknown
White/Caucasian
Other
Prefer not to answer
Required
Languages Spoken
*
Your answer
Grade
*
6th Grade
7th Grade
8th Grade
School
*
Choose
Talent Middle School
McLoughlin Middle School
Ashland Middle School
Parent Guardian Information
Parent/Guardian First Name
*
Your answer
Last Name
*
Your answer
Relationship To Youth
*
Mother
Father
Grandmother
Grandfather
Foster Parent
Other:
Parent/Guardian Phone Number
*
Your answer
Type
*
Cell Phone
Work Phone
Home Phone
May Rogue Valley Mentoring text this number with info and updates relevant to the youth?
*
Yes
No
Parent Guardian Email Address
*
Your answer
Is the Parent/Guardians address different from the mentee's ?
*
Yes
No
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