Athletes for Kids Child Information 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... Bellevue High School, Bellevue, WA Eastside Catholic High School, Sammamish, WA Eastlake 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 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 firstname.lastname@example.org) Current Grade Please select... First Second Third Fourth Fifth Sixth Seventh Eight Ninth(If outside this age range please e-mail us at email@example.com) 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 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 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? (check all that apply) Confidence Classroom behavior Self esteem Friendship Social skills Other Happiness 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. Total household incomePlease select... Under $20,000 $20,000-$30,000 $30,000-$40,000 $40,000-$50,000 $50,000-$75,000 $75,000-$100,000 $100,000-$150,000 $150,000 or more Prefer not to answer Single parent household Yes No Number of persons in householdPlease select... 2 3 4 5 6 7 8 Is either parent a US Veteran? Yes No Race of child (select all that apply) White/Caucasian Alaska Native African American Latino American/Hispanic Native Hawaiian/Pacific Islander American Indian Asian Other What is the primary language spoken at home? 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. Please select... I will pay this fee when my child is matched I will apply for a partial or full scholarship Note: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 reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Need assistance with this form?