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Positive Vibes Ronjanae Smith Inc.

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Become a Mentee

Unlock Your Potential with Our Boys’ Mentoring Program!

Are you ready to take charge of your future? Join our Boys’ Mentoring Program and discover how a supportive mentor can help you reach your goals!

Phone :

Email :

843-955-4569

pvrsinc07@gmail.com

Social Media :

Child's Information:

Child's First Name*

Child's Last Name*

Child's Birthday*

Month

Day

Year

Child's Age*

Gender M/F*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

School Name*

Grade Level*

T-Shirt Size*

Parent/Guardian Information:

First Name*

Last Name*

Relationship to Child*

Phone*

Multi-line address

Country/Region

Address

City

Zip / Postal code

Email*

Alternate Phone Number*

Upload Drivers License or ID*

Emergency Contact Information

Full Name*

Relationship to Child*

Phone

Medical Information

Does your child have any allergies?*

Yes

If answered yes, please list*

Does the child have an y medical conditions we should be aware of?*

Yes

If answered yes, please list*

Is the participant currently on any medications?*

Yes

If answered yes, please list*

Mentorship Intake

Reason for Enrollment*

Why do you think your child need a mentor?*

Child's Interest: (Please list)*

Challenges or interest needing support?*

Has your child been arrested?*

Yes

If yes, what was the charge?*

Is your child court ordered?*

Yes

Does your child have an upcoming court date due to the charger?*

Yes

When is the upcoming court date?*

Which county for the upcoming court date due to the charge?*

Does your child have a Probation Officer or have been assigned one? If yes please provide the Probation Officer contact information below:*

Yes

Probation Officer Full Name/Phone Number*

If your child currently on probation or house arrest? If yea, how long is your child's probation or house arrest period*

Yes

Probation House Arrest Start Date and End Date*

Child's Signature*

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Date

Month

Day

Year

Parent/Guardian Signature*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date*

Month

Day

Year

2021 by Positive Vibes Ronjanae Smith Inc.

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