MEN OF PROOF Male Mentoring Program Registration & Waiver Building Stronger Boys. Creating Better Men. Participant Information Participant Full Name* First NameLast Name Age* Date of Birth* -Month -DayYearDate Gender* MaleFemale School Name* Grade Level* Please Select K 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th College Other Phone Number* Please enter a valid phone number.Format: (000) 000-0000. Email Address* example@example.com Home Address* Street Address Street Address Line 2CityState / ProvincePostal / Zip Code Please Select Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country City* State* Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other Zip Code* Parent/Guardian Information Parent/Guardian Full Name* First NameMiddle NameLast Name Relationship to Participant* Please Select Mother Father Guardian Grandparent Other Parent/Guardian Phone Number* Please enter a valid phone number.Format: (000) 000-0000. Parent/Guardian Email Address* example@example.com Emergency Contact Name* First NameMiddle NameLast Name Emergency Contact Phone Number* Please enter a valid phone number.Format: (000) 000-0000. Program Interest Program Interest* Youth MentorshipLeadership DevelopmentBrotherhood & Group MentoringFitness & Wellness ActivitiesCommunity Service OpportunitiesRecreational Trips & Exposure ActivitiesBusiness & Career ExposureVolunteer OpportunitiesBecoming a Mentor Short Response Questions Why are you interested in Men of Proof?* What are some goals you want to work on personally?* Is there anything you would like mentors to know about you? Medical & Safety Information Allergies Medical Conditions Current Medications Special Accommodations Needed Doctor Name Doctor Phone Number Please enter a valid phone number.Format: (000) 000-0000. Communication Opt-In Text Message Opt-In* I consent to receive text messages about schedules, program updates, events, reminders, opportunities, and important announcements. Message and data rates may apply. Email Opt-In* I consent to receive emails about mentorship programming, opportunities, updates, events, and community announcements. Signatures Parent/Guardian Signature* Date* -Month -DayYearDate SubmitSubmit Should be Empty:
