Parent/Legal Guardian's Full Name *

First Name

Last Name

Parent/Legal Guardian's Phone Number *

(###)

###

####

Student's Full Name *

First Name

Last Name

Student's Date of Birth *

MM

DD

YYYY

Student's Current Grade *

5th Grade

6th Grade

7th Grade

8th Grade

9th Grade - High School Freshman

10th Grade - High School Sophomore

Address *

The Student's Current/Primary Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please Select the Reason(s) for Your Application *

My Son is Not Performing in School

My Son Needs a Good Male Role Model/Better Influences

I'm Worried My Son is Engaging with the Wrong Crowd or Risky Situations

What is Your Child's Ethnicity? *

American Indian or Alaskan Native

Asian or Pacific Islander

Black or African American

Hispanic or Latino

White / Caucasian

Prefer Not to Answer

Does a male over the age of 18 live in the same house as the student? *

Yes

No