5th Grade Girl's Circle

Who is the person completing this form?*

5th Grader
Parent/Guardian of 5th Grader
Community Partner Referring

Community Partner

Community Partner: Please share who you are*

Community Partner: Has the child asked & agreed to participate in this circle?

Yes
No

5th Grader

5th Grader's Full Name*

First Last

Preferred Name (Nickname)

5th Grader's Pronouns*

She, her, hers
He, him, his
They, them, theirs

5th Grader's Gender*

Male
Female
Non binary

5th Grader's Ethnicity*

5th Grader's Date of Birth*

5th Grader's School*

Parent/Guardian's Phone*

Parent/Guardian's Email

Has the 5th Grader requested to join this community-based circle?*

Yes
No

What does the participant hope to get out of this community-based circle with other 5th-grade girls?

Does 5th Grade participant have any dietary allergies or restrictions?

5th Grader Preferences

What are some values and beliefs that are important to you?

Preferred activity setting?

Indoor
Active

Please list skills, hobbies, interest, languages, etc.

Is there anything else the 5th Grade participant would like Rogue Valley Mentoring to know?

Parent/Guardian #1

Parent/Guardian #1 Full Name

First Last

Parent/Guardian #1 Relationship to 5th Grader

Parent/Guardian #1 Full Address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian #1 Phone

Parent/Guardian #1 Email

Parent/Guardian #2

Parent/Guardian #2 Full Name

First Last

Parent/Guardian #2 Relationship to 5th Grader

Parent/Guardian #2 Full Address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian #2 Phone

Parent/Guardian #2 Email

Agreements and Signature

Additional Comments

Send 5th Grade Girl's Circle confirmation email to this email address.*

Agreement*

By checking 'Yes', I agree that all information provided above is correct. This will act as a digital signature confirming this.

Yes

Signature*

Please sign the form, using your finger on a touch device, or mouse on computer

Email

This field is for validation purposes and should be left unchanged.