Mentee Registration Form Required fields are marked with an asterisk (*) Personal Information First Name This field is required. Last Name This field is required. Current Address This field is required. City This field is required. Province This field is required. - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code This field is required. Age This field is required. - Select -16171819 Cell Phone # This field is required. Email Address This field is required. My preferred form of communication: Cell Phone # Email Address *Please note: The majority of communication about the mentorship program will be sent using your preferred method of communication Emergency Contact Information Contact First Name This field is required. Contact Last Name This field is required. Relationship to you This field is required. (i.e. guardian, CAS worker) Contact Phone # This field is required. Contact Email Address This field is required. What are your Interests? We want to know what you like to do and what your interests are so that we can create some fun and engaging activities for you. Please select all your interests Criminal Justice Environmental Issues Fashion Reading/Writing/Poetry Social Work Diversity Awareness Film Theatre/Acting Activism World Religions Painting Sports Current Events International Relations Photography Outdoor Activities Travelling Arts/Crafts Music Dance Politics Architecture Documenntaries Volunteering Other… Specify your own value: Education Are you in secondary school? This field is required. - Select -YesNo If yes, what grade are you in? - None -9101112 If no, have you graduated from high school? - None -YesNo More About You Nipissing University and the Crown Ward Mentorship Program is committed to accessibility for persons with disabilities. Please contact us if you have any particular accessibility requirements. Contact: Crown Ward Mentorship Program, firstname.lastname@example.org or call 474-3450 ext. 4241. Please indicate if you have any dietary restrictions and/or allergies - None -YesNo Please specify in the box provided your dietary restrictions and/or allergies Consent All participants must read, sign and submit the Activities Authorization Consent Form and Waiver provided HERE. If a participant is under 18 years old a guardian and/or CAS worker must also sign. This form can be submitted by email to email@example.com or in person on the first day of participation in the mentorship program. Please sign your full name in the box below This field is required. By signing your name above, you have will have successfully registered as a student participant in this program. You clearly understand what you are agreeing to do, you have read and understood this registration form, and have had any questions, concerns or complaints answered to your satisfaction.