Mountain Mentors Youth Application

Thank you for your interest in Mountain Mentors. Please fill out the following to the best of your ability. After receiving your application, Mountain Mentors staff will reach out to schedule an interview with you and your child. Please fill out separate applications for each child you wish to enroll in the program.

Youth Information

First Name *This question is required.

Middle Name

Last Name *This question is required.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Gender *This question is required.

Race or Ethnicity *This question is required.

If you said other, please specify.

If you said other, please specify. *This question is required.

Parent or Guardian Information

First Name *This question is required.

Middle Name

Last Name *This question is required.

Primary Phone Number *This question is required.

Secondary Phone Number

Email Address *This question is required. This question requires a valid email address.

Would you like to add a secondary guardian? *This question is required.

Secondary Parent or Guardian Information

Full Name *This question is required.

Primary Phone Number *This question is required.

Secondary Phone Number

Email Address *This question is required. This question requires a valid email address.

Address

Mailing Address *This question is required.

Apt/Suite

City *This question is required.

Zip *This question is required.

Is your physical address the same as your mailing address? *This question is required.

Physical Address *This question is required.

Apt/Suite

City *This question is required.

Zip Code *This question is required.

Child's Phone Number

Child's Email Address This question requires a valid email address.

Are there additional children in the household? *This question is required.

ADDITIONAL CHILDREN IN THE HOUSEHOLD
Select "Add Another" to add additional members

Name

Age

Relationship to Applicant

If you said other, please specify. *This question is required.

LIVING SITUATION:
Please describe your child’s living situation, including any relevant information about custody status or household members.

Mountain Mentors Youth Application

(to be filled out by parent or guardian)