Become a dreamer

Personal Information

Date of Birth

Please answer all of the following questions as completely as possible.

Please complete all the following. This survey will help Realize Your Potential Youth Society know more about you and your interests and help us find a good match for you.

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Please read this carefully before submitting.

Realize Your Potential Youth Society appreciates you and your child's interest in his/her becoming a mentee. This application is intended to inform and gain the parent/guardian's consent to allow their son/daughter to participate in the NewLife Youth ReGeneration Program™.

After receiving the completed application form, we will evaluate the information and inform you if your child has been accepted into the program. The information you supply in this packet will be used to determine your child's eligibility. Therefore, the mentoring staff may, at times, need to access and share this information with other parties when necessary.

I give my informed consent and permission for my child to participate in the NewLife Youth ReGeneration Program™ and its related activities.

I agree to have my child follow all mentoring program guidelines and understand that any violation on my child's part may result in suspension and/or termination of the mentoring relationship.

I agree to allow Realize Your Potential Youth Society to use any photographic image of my child taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.

I understand I must return all of the following completed items along with this application and that any incomplete information will result in the delay of my application being processed.

I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

Contact and Information Release

I hereby grant permission for the Realize Your Potential Youth Society to make contact with my child and conduct a personal interview for the purposes of applying to be a mentee. The Realize Your Potential Youth Society may also make contact with my child on school premises for the purposes of screening and interviewing as well as ongoing support of his/her participation in the mentoring program

I authorize the Realize Your Potential Youth Society to obtain any needed information regarding my child from his/her school's staff, including academic and behavioral records and conversations with teachers, counselors, and other administrative staff

Further, I understand that basic information about my child may be shared with other members of RYP to aid in determining suitable program activities.