I'RAISE Girls & Boys International Corporation Application for Virtual Mentoring Services
Please complete one application per child.
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Parent/guardian Name *
 Child Names *
(Last, First)
Child Date of Birth *
(mm-dd-yy)
Phone Number *
Email Address *
Address *
Street Address, Borough, Zipcode, State
What School does your child attend? *
What grade is your child in? *
Does your child have any special needs, if yes, please specify below. *
What type of mentoring services are you interested in? *
What are your days and times of availability for child to meet with mentor virtually? *
Days, Times
How many years have your child received mentoring services before? *
How long will you like to receive virtual mentoring services? *
Why are you interested in receiving virtual mentoring services for your child? *
Are you interested in any of the additional virtual programs we offer for children and families? *
Required
Does your child have access to BOTH a device and internet to access virtual mentor sessions? If answered no to either question, specify below *
When would you like your child to start virtual mentoring services? *
MM
/
DD
/
YYYY
Do you have any preferences for the mentor assigned to your child? For example: gender, age, profession etc. If none, please respond none. *
What are some activities your child enjoy doing for fun? *
Please indicate what virtual activities you are interested in for your child. *
Required
Do you currently receive any of the following benefits for yourself or your child/ren? *
Have you or your family been impacted by COVID-19? If so, please specify explain below *
Are you or your child/ren in need any of the following as a result of COVID-19 *
Required
By initialing below, I attest that I have completed the form accurately and to the best of my knowledge. I understand that my child acceptance is contingent upon availability. I'RAISE Girls & Boys International Corporation will do its best to process every application timely,  however there may be instances when your child may be placed on waiting list due to the volume of applications. (Please initial first and last name) *
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