In-School Mentoring - Child Application Form

Please choose your child’s school from this list, or “other” if their school not listed and share the school name.*
Full name of the child*
First Last
Birthdate*
MM slash DD slash YYYY
Gender identity of the child*
Full Name of Parent/Guardian*
Relationship to the child?*
Address*
Street Address Address Line 2 City Province Postal Code
Email Address*
Enter Email Confirm Email
Home Phone*
Cell Phone*
OPTIONAL - Work Phone
Emergency Contact
Please ensure this person is someone other than the parent/guardian, and they must have a phone number that is different from the parent/guardian.
Emergency Contact's Full Name*
Relationship to Child*
Home Phone*
Cell Phone*
What school is your child enrolled in?*
What grade is your child currently in?*
Please list at least four of your child's interests and favourite activities to help us match your child to a Mentor who shares similar interests.*
Where did you hear about the program?*
The following optional information is asked for statistical purposes and for grant/funding support. The questions and responses do not indicate or affect participation requirements.
OPTIONAL - What ethnicity is your child?
OPTIONAL - Was your child born in Canada?
If not, how long as your child lived in Canada?
Languages Spoken
Is there anything else you would like to share with us or that may be important for us to know?

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In-School Mentoring – Child Application Form