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E4 – Youth Empowerment Signup Form
Contact (541)-729-2045 with any questions!
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Name
*
First
Last
Email
*
Phone Number
*
Birthday
*
(XX/XX/XXXX)
Gender
*
Male
Female
Other
Prefer not to say
Race / Ethnicity
*
African-American
Latino
Asian
White
Other (please specify down below)
Grade Level
Elementary School (K-5)
Middle School (6-8)
High School (9-12)
Why are you interested in getting a mentor? Are there any particular things you'd like a mentor to help you with?
*
What special interests, hobbies, or leisure activities do you enjoy when you're not in school or at work?
*
Phone enjoy share
Please share any additional information about yourself which can help to match you with a mentor.
Submit
