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We welcome your Son or Grandson
To the wonderful world of America's Young Gentlemen Mentoring Program

Mentees Name *

Age: *

Grade: *

Phone/cell:

Email: *

Mentee Birthday: * / /

Are you commited to completing the first 16 weeks? *

Yes
No

School attending? *

Favorite academic subject? *

Family household status: *

Two Parent Household
Single Family Household

If single family list primary parents name:

Mothers name: *

Primary Parent E-mail Address: *

Home phone:

Cel phone:

Email:

Address:

City:

State:

Zip:

Mailing address if different than above:

Fathers name:

Home phone:

Cell phone:

Email:

Address:

City:

State:

Zip:

Name of Grandparent registering grandson:

Grandparent address, Home & Cell Phone:

Would you like to receive the AYGMP newsletter? *

Yes
No

What development areas would you like to see your son improve in?

I'm a Guardian or Fosterparent:

Guardian
Foster Parent

Name:

Address:

Home Phone:

Cell Phone:

How will you like to structure your payments? *

* Required