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Name of Mentee:
Age of Mentee:
Mentee Cell Number:
Mentee Email:
Mentee Birthday:
Mentee School Name:
Mentee Grade:
Mentee Graduation Date:

PARENT / GUARDIAN INFORMATION

Father's / Guardian Name:
Father's Cell Number:
Father's Email:
Father's Address:
Mother's / Guardian Name:
Mother's Cell Number:
Mother's Email:
Mother's Address:

SECONDARY CONTACTS

Emergency Contact Name:
Emergency Contact Phone:

MEDICAL HISTORY

Does your child have any food allergies?:

HANDBOOK

I have read and agreed to the terms of the Operation Timothy - Rites of Passage Handbook. I understand the behavior that is required of my child.:
YesNo

Mentee Hobbies/Sports

Student's Sports (Check all that apply):
BasketballBaseballFootballTrack & FieldSoccerLacross