Student Name * Parent/Guardian Name * Relationship to Student * Street Address * City * State * Zip * Parent Phone Number * Parent Email * Age * 11 12 13 14 15 16 17 Student Name of School * Student G.P.A * Student Grade Level * Emergency Contact Name * Phone Number * Student Shirt Size * Small Medium Large XLarge XXLarge Application Questions
Please answer all the following questions as completely as possible. The answers to these questions will help
us create positive outcomes by providing opportunities, fostering positive relationships, and giving each
student the support needed to develop leadership skills.
1. Why do you/your child want to participate in Life Skool Leadership Mentoring Program? * 3.Is your child available to attend scheduled classes twice weekly on Tuesdays and Thursdays and two Saturdays out of the month? * Please explain any scheduling issues that you may have. * 4.Describe your child's school performance, including grades, homework, attendance, and behavior at home. * 5. Is your child currently on parole or probation? If so, please provide the details of the offense. * Paragraph Text 6. Has your child experienced any traumatic events (i.e., death in the family, abuse, divorce)? If yes, please provide details. * 7. Can you provide additional background information that may help us determine program acceptance determination? (Anything that we should be aware of that could be a trigger for you or your child.) * Medical Insurance Provider * Policy Number * Phone Number * Does your son have any physical problems or limitations? * Is your son receiving treatment for any medical issues? * Does your child currently take any medications? * If yes, please explain. * Does your son have any known allergies or adverse reactions to medications?If yes, please explain. *
Please read this carefully before signing:
We appreciate you and your child's interest in becoming a student in our leadership mentoring program.
This application is intended as a means of informing and gaining the consent of the parent/guardian to allow
their son/daughter to participate in the leadership course and community events.
After receiving your completed application, we will evaluate the information and send you a letter letting you
know if your child has been accepted into the Life Skool Leadership Mentoring Program. Much of the
information you supply in this application packet will be used to determine if this program is the right fit for
you and your child. This information will be kept confidential and only shared with senior staff who choose
acceptance status.I understand that I must return all the following completed items along with this application and that any
incomplete information will result in the delay of this application being processed:
Contact and Information Release Form
Program Agreement Form
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the
above terms and conditions.
If you have any questions regarding this application or the process, please email us at Lifeskool@dariuspettway.org or call us