Contact 1 — Men of Purpose

REgister your child today

Attention: Registration must be completed by an adult parent or guardian; as mentees are under the age of 18 and require parental permission for participation.

Registration Fee: $150 per year

info@menofpurposementoring.org
(773) 787-5801
Chicago, IL 60628

Mentee's Name

First Name

Last Name

Mentee's Birth Date

YYYY

Mentee's Current Age

Mentee's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mentee's School Name

Mentee's Grade Level

Health

Does Mentee have any ALLERGIES?

If Mentee has allergies, please list ALLERGIES below:

If no, please put NA and continue completing Registration Form.

Does Mentee have any health conditions we should be aware of:

Please list health conditions below:

If no, please put NA and continue completing Registration Form.

Mentee's Email

Mentee's Shirt Size

Mentee's Social Media Handle/Name

Parent's/Guardian's Name

First Name

Last Name

Parent's/Guardian's Cell Phone

(###)

###

####

Parent's/Guardian's Work Phone

(###)

###

####

Parental MOP Commitment

Are you willing to give a minimum of 5 hours of your time?

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

Media Release Consent

I hereby give permission for media related materials of my child, captured during any/all Men of Purpose programming and events (inclusive but not limited to: photo and digital camera images) to be used solely for the purposes of MOP promotional material and publications, and waive any rights of compensation or ownership thereto.

Parent/Guardian Signature of Consent for Participation

By typing my full name below, I acknowledge that I am providing consent for my child (listed above) to be a member and mentee in the Men of Purpose Mentoring Program, known as MOP.

First Name

Last Name