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SHYEP Participants Form

Child Informations

Full Name

Childs Email *

It will be used for the portal

Date of birth

Gender *

Male

Female

Prefer not to say

School Name *

ChildPhone Number

Child Current Grade

Child Favorite Hobbies

Parent/Guardian Information

Guardian Name

Phone *

Email *

Relationship to Child

Preferred Method of Communication *

Phone

Text

Emergency Contact Information
(In case we are unable to reach the parent/guardian.)

Emergency Contact Name

Relationship to Child

Emergency Contact Number

Medical & Special Considerations

Does your child have any allergies? *

Yes

If yes, please list:

Does your child have any medical conditions or special needs we should be aware of? *

Yes

If yes, please describe:

Option 1
Option 2
Option 3
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What are your expectations for your child’s participation in the mentorship program? *

Are there specific skills or areas of development you’d like us to focus on?

Parent Consent

I, [Parent/Guardian Name], give permission for my child, [Child’s Name], to participate in the Shepherd’s Haven Youth Mentorship Program. I understand that my child will be engaging in mentorship activities and agree to abide by the program guidelines.

Parent/Guardian Signature:

Clear

I Consent to Receive SMS Notifications, Alerts from Shepherd's Haven Community Development Corporation. Message frequency varies. Message & data rates may apply. Text HELP to +1 910-971-2037 for assistance. You can reply STOP to unsubscribe at any time.

By checking this box I agree to receive occasional marketing messages from Shepherd's Haven Community Development Corporation.

Contact us!

100 Hay St, Suite 704 , Fayetteville NC 28301

(910) 971-2037

[email protected]

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Terms & Condition

100 Hay St suite 704, Fayetteville, NC 28301, USA