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If you are under the age of 18, you must list your parent's information.

First Name *

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Last Name *

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Name you prefer / nickname

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Email *

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Mobile Phone *

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Home Phone

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Address Line 1 *

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City *

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State/Province *

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Zip/Postal Code *

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Country

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Grade Level *

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School Name *

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Birthday *

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Sports *

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Groups/Clubs/Personal Interests (art, music, gaming, etc) *

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Why are you seeking mentorship? *

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#1 Parent/Guardian Full Name

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#1 Parent/Guardian Mobile *

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#1 Parent/Guardian Email *

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Employer Name & Occupation *

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Do you have any special skills or expertise that you can contribute to the program? (fundraising, health & wellness, financial planning, etc) *

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#2 Parent/Guardian Full Name

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#2 Parent/Guardian Mobile

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#2 Parent/Guardian Email

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Employer Name & Occupation

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Special Skills/Expertise (fundraising, health & wellness, financial planning, etc)

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Emergency Contact Full Name *

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Emergency Contact Phone Number: *

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Emergency Contact Relationship: *

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Report Card

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Please upload your most recent report card or transcript.

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Parent/Guardian Name *

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Participation Agreement *

By submitting this application, I affirm that the facts set forth in my application for participating are true and complete. Thank you for completing this application form and for your interest in participating in our Boss program. All the information recorded above is considered confidential.

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