1. Child Enrollment Form Child Name: ____________________________
Age:_______________ Date of Birth: _____________________
Gender: ____________________
Guardian Name: ______________________________________
Relationship to Child: _____________________
Address:__________________________
City:___________________________ County:______________________
State:_______ Zip: ________________
Phone #:__________________ _____________________________
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