TUTORING/MENTORING PROGRAM:

FRANCOPHONE MINISTRY
Child’s Name: __________________________________________________________________
Last Middle First

Date of Birth ____________________________

School Attending ___________________________________ Grade ______________________

Parents Name ___________________________________ Phone ( ) __________________

Home Address: ________________________________________________________________

City: ________________________ State: ______________ Zip Code _____________________

Email: __________________________________

Emergency Contact Person: ______________________________________________________

Relationship to Child: _________________________

Emergency Hospital to Go: _______________________________________________________

Allergies: Y N (List) _____________________________________________________

_____________________________________________________________________________

Medical Concerns: Y N (Explain) ___________________________________________

_____________________________________________________________________________

I, ___________________________, am filling this form as parent/guardian of this child I

have understood the responsibilities and agree to send my child to attend this program and all the
benefits that come along with it.

Signature of Parent: ______________________________________ Date: __________________