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Mothers With Mentors Kick-Off RSVP
Saturday, May 4th @ 10:30 AM (One Hour Meeting)
*
Indicates required field
Name
*
First
Last
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Ethnicity
*
African American or Black
White
Asian
American Indian or Alaska Native
Hispanic or Latinx
Native Hawaiian or Pacific Islander
Multiple Ethnicity/ Other
Birthdate: (Example: 01/29/1985)
*
Emergency Contact Name:
*
Emergency Contact Phone Number:
*
Are you a Mentor or Mentee?
*
Mentor
Mentee
If you are a Mentee, will your children be attending this event?
*
Please list the NAMES, AGES, & GENDERS of your children attending this meeting:
*
Additional Comments
*
Location Note:
*
I understand that the location of this meeting will be sent upon program acceptance approval via email and I am responsible for my own transportation to this event if this request is approved.
Agreement
*
I agree that this information is correct. I also agree that Shelter From the Rain is not responsible for anything lost, stolen, or injured during this event if my request is approved.
Submit