Child Registration Buddy Application Child First Name Child Last Name Home Phone Date of Birth RegistrationPlease select... New Registration Rematch GenderPlease select... Male Female Other Current School Feeder High School Please select... Eastlake High School, Sammamish, WA Eastside Catholic High School, Sammamish, WA Issaquah High School, Issaquah, WA Juanita High School, Kirkland, WA Lake Washington High School, Kirkland, WA Liberty High School, Renton, WA Mercer Island High School, Mercer Island, WA Mount Si High School, Snoqualmie, WA Newport High School, Bellevue, WA Redmond High Schools, Redmond, WA Skyline High School, Sammamish WA(If your child's school is not on this list, please e-mail us at afk@athletesforkids.org) Current Grade Please select... First Second Third Fourth Fifth Sixth Seventh Eight Ninth Tenth Eleventh Twelfth(If outside this age range please e-mail us at afk@athletesforkids.org) Additional Information Why are you interested in a mentor for your child? How did you hear about our program?* Medical Information Primary DisabilityPlease select... ACE ADHD Anxiety ASD (autism) Bipolar Cerebral Palsy Depression Developmental disability Down syndrome Hearing disability Learning/intellectual disability OCD/ODD Physical disability PTSD Sensory processing disorder Speech disability Tourette’s Vision impairment Other Secondary DisabilityPlease select... ACE ADHD Anxiety ASD (autism) Bipolar Depression Developmental disability Down syndrome Hearing disability Learning/intellectual disability OCD/ODD Physical disability PTSD Sensory processing disorder Speech disability Vision impairment If you selected 'other' disability, please provide the reason for being referred. Please provide the name and contact information of the school or medical professional Does your child have IEP/504?Please select... Yes No Hospital/Clinic Preference Any medical conditions, restrictions, allergies Say none if not relevant Specific instructions if a medical emergency occurs Child's Home Address Street City StateWA Postal Code Parent/Guardian #1 (Required) First Name Last Name Parent Email Cell Phone Company Occupation Does your company match donations? Please select... Yes No Don't know Please provide name and email address of ALL adults (18 years and older) in your household.Note: Since the Mentor will be visiting YOUR home, we run a WA State Background Check on ALL adults living in your household. Email address for each adult is needed, so we can email each adult a Background DocuSign form. Home Address Same as above Different address Parent / Guardian # 1Address Street City StateWA Postal Code Parent/Guardian # 2 First Name Last Name Email Cell Phone Company Occupation Does your company match donations? Please select... Yes No Don't know Home Address Same as above Different address Parent / Guardian # 2 Address Street City StateWA Postal Code Goals What areas of improvement would you like to see in your child through a mentorship relationship? Confidence Classroom behavior Self esteem Friendship Social skills Other Happiness Check all that apply Demographic Information Providing this information helps Athletes For Kids receive critical funding. As with all of the information we collect, your demographic information will be kept confidential and never shared. Single parent householdYes Number of persons in householdPlease select... 2 3 4 5 6 7 8 Did either parent serve in US military (Past or present)?Please select... Yes No Prefer not to answer Race of child (select all that apply) White or Caucasian Alaska Native African American Latino American or Hispanic Native Hawaiian or Pacific Islander American Indian Asian Other Prefer not to answer What is the primary language spoken at home? Do you have limited ability to read, speak, write, or understand English?Please select... Yes No Are you an immigrant or refugee? Please select... No Yes Prefer not to answerAnyone who was not born in the US is considered an immigrant regardless of status. If they were born in another country and have a green card, are naturalized, or are undocumented, they would count as an immigrant or refugee. Are you homeless?Please select... No Yes Prefer not to answer Total Household IncomeAbove $90,000Below $90,000Below $70,000Below $50,000Below $40,000Prefer not to answer Below $90,000 Please provide the household Income (if below $90,000). Providing this information helps Athletes For Kids receive critical funding. Emergency Contact # 1 / Nanny / Caregiver Information (Required) First Name Last Name Cell Phone Emergency Contact # 2 (Required) First Name Last Name Cell Phone Program Athletes For Kids spends approximately $1,200 to maintain and support each mentorship per year. We ask all mentee families for a nominal mentorship fee of $240/year, payable monthly, quarterly, or annually beginning once the child has been matched. Note: Full and partial scholarship are available for those who apply (See options below). Mentorship fee or scholarshipPlease select... I will pay this fee when my child is matched I will apply for a partial or full scholarship Full Scholarship as my child is on free and reduced-priced meals reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Contact Information
