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* 1. Enter MENTEE full name, ADDRESS, CELL PHONE (ANSWER ALL QUESTIONS)

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* 2. Enter your DATE OF BIRTH AND GRADE IN SCHOOL

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* 3. Parents Full name and cell phone

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* 4. Emergency contact name, relationship, and phone number

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* 5. School attending this year?

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* 6. Extra curricular activities or hobbies

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* 7. Does your child take any special medications (epi-pen, asthmas inhaler) or have any behavior issues? If so, list medications, allergies, special conditions below.

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* 8. Do you give permission for use of any photo of my child to be used by F.U.E.L., Inc for public relations?

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* 9. What are some of the things you want to get from this mentoring program?

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* 10. I hereby represent that the mentee is a minor, I am her guardian and authorized to provide the releases and permissions as stated and all information above is accurate and complete. I hereby give permission for my child to participate in all program activities and agree to release F.U.E.L., Inc, it's officers, and staff, from all liability arising from any harm or injury incurred by the participation of my child in the program stated above. Please print full name and date.

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