Child Enrollment Form Child Name: ____________________________ Age:_______________ Date of Birth: _____________________ Gender: ____________________ Guardian Name: ______________________________________ Relationship to Child: _____________________ Address:__________________________ City:___________________________ County:______________________ State:_______ Zip: ________________ Phone #:__________________Email: _____________________________ Why do you feel this child might benefit from a mentor? What particular interests either in or out of school do you know of that the child has? Updated January 17, 2010 AN AMACHI PROGRAM SPONSORED BY NORWESCAP, INC. WITH SUPPORT FROM THE NICHOLSON FOUNDATION AND CORPORATION FOR NATIONAL COMMUNITY SERVICE