Barbershop U: INTEREST APPLICATION

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Email *

Participant First Name *

Participant Last Name *

Nickname *

Street Address *

City *

State *

Zip Code *

Birthdate *

YYYY

Age *

Program: Age Group (Choose Only One) *

10-13

14-17

18-24

Required

Grade (If none, write N/A) *

School (If none, write N/A) *

PARENT/GUARDIAN SIGNATURE (if under 18)

I ___________________________ give permission for my child/ward to participate in the Youth Mentoring Program. I will make arrangements and be responsible for my child’s attendance at all meetings, events/activities.

Parent's First and Last Name *

Today's Date *

YYYY

A copy of your responses will be emailed to the address you provided.

Submit

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