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CREATING OUR FUTURE, INC

YOUTH MENTORING PROGRAM REGISTRATION FORM (Please Print) Today’s date:

High School:

(STUDENT)REGISTRATION INFORMATION Student Last Name:

First:

Parent(Guardian)

First:

Street address:

P.O. box:

G.P.A.

Middle:

Birth Date / /

Grade

One on Group  Tutoring One Workshops If your child needs extra tutoring services, additional charges may apply

Cell Phone no:

Home phone no.:

(

(

) State:

M

F

XL

XXL

) ZIP Code:

T-Shirt Size S M $35.00 Registration Fee Includes Yearly 6 month session session Price

L

Workshops

Travel

More than one child please fill out separate forms. Thank You!

IN CASE OF EMERGENCY Name of local friend or relative:

Relationship to Student:

Home phone no.: Cell phone no: (

Parent/Guardian signature

WEBSITE: www.creatingourfutureyouth.org

)

(

)

Date

PHONE:470-59-4447

 F

Sex:

Career Interest:

Chose type of mentoring (please check box):

 M

Middle:

City:

/

Sex

Age

EMAIL:creatingourfutureinc@gmail.com

Creating our future student registration form 1  
Creating our future student registration form 1  
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