Child Mentoring Application Today's Date* Date Format: MM slash DD slash YYYY Name of Child* First Last Child's Gender*MaleFemaleChild's Date of Birth* Date Format: MM slash DD slash YYYY Child's Ethnic Affiliation/Race*School Child Attends*Current Grade Level*Name of Parent* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone Number*Work Phone NumberCell Phone NumberEmail Address* CAPTCHANameThis field is for validation purposes and should be left unchanged.