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New Family Pre-Registration Application

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New Family Pre-Registration Application

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New Family Pre-Registration Application
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CURRENTLY ENROLLING FOR FALL AFTER SCHOOL 2023-2024

Please note that this form must be filled out by a legal parent or guardian of the student(s). All fields with a * indicator require a response. You will not be able to complete the application if any required fields are not completed with a response.

By filling this out and clicking "Save" you confirm that you are a legal parent or guardian and are willing to abide by and enforce our student/parent contract.

By submitting this form to MentorKids USA you are confirming that you have read and agree to our:

Student-Parent Contract Form
Mandatory Reporting Disclosure
Liability Release Form
Homework Release Form
Trip Release Form

If you would like to request a copy of these documents please email your neighborhood team.

South Phoenix: sppnregistration@mentorkidsusa.org

Palomino: palominoregistration@mentorkidsusa.org

Paiute: paiuteregistration@mentorkidsusa.org

Maryvale: maryvaleregistration@mentorkidsusa.org

Tempe: temperegistration@mentorkidsusa.org

Family Pre-Registration

Visit Information

Campus

Campus is required.

Adult Information

First Adult

First Name

Last Name

Gender

Gender is required.

Birthdate

Birthdate is required.

Marital Status

Marital Status is required.

Mobile Phone

Mobile Phone is required.

Email address is not valid

Email is required.

Employer

Legal Parent Guardian

None Yes

E-mail Release

None Yes No

Second Adult

First Name

Last Name

Gender

Birthdate

Marital Status

Mobile Phone

Email address is not valid

Employer

Legal Parent Guardian

None Yes

E-mail Release

None Yes No

Address

01.1-First Emergency Contact/Authorized Pickup Full Name

01.1-First Emergency Contact/Authorized Pickup Full Name is required.

01.2-First Emergency Contact/Authorized Pickup Phone Number

01.2-First Emergency Contact/Authorized Pickup Phone Number is required.

01.3-First Emergency Contact/Authorized Pickup Relation to Student

01.3-First Emergency Contact/Authorized Pickup Relation to Student is required.

02.1-Second Emergency Contact/Authorized Pickup Full Name

02.1-Second Emergency Contact/Authorized Pickup Full Name is required.

02.2-Second Emergency Contact/Authorized Pickup Phone Number

02.2-Second Emergency Contact/Authorized Pickup Phone Number is required.

02.3-Second Emergency Contact/Authorized Pickup Relation to Student

02.3-Second Emergency Contact/Authorized Pickup Relation to Student is required.

05-Does your family receive any of these Government Assistances?

Nutrition Assistances AHCCCS Cash Assistances OTHER05-Does your family receive any of these Government Assistances? is required.

06-Estimated Family Income

06-Estimated Family Income is required.

07-Family System

07-Family System is required.

08-Family Investment

Tutor BIble Study Reading Buddy Arts and Crafts Sports Donating Supplies Monetary Contribution08-Family Investment is required.

09-Does your family regularly attend church?

Yes No

09-Does your family regularly attend church? is required.

10-Please list the name of the church you attend

11-What is your connection to your Promise Neighborhood?

11-What is your connection to your Promise Neighborhood? is required.

12-Reduced Lunch

Yes No

12-Reduced Lunch is required.

13-How did you hear about MentorKids?

13-How did you hear about MentorKids? is required.

Children

Add Child

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1776 N Scottsdale Rd # 1148 Scottsdale, AZ 85252-3647