Parental Mentoring Enrollment Form FOR THE FAMILY, INC. MENTOR ENROLLMENT Name*Date of Birth* MM DD YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone NumberE-mail* I am a parent*YesNoStatus*SingleDivorcedMarriedNumber of Children*How Old Are They?ALL INFORMATION IS TOTALLY CONFIDENTIAL. Please list the issues that you are able to guide someone through (1=most serious, 5=least serious):CHILDRENParenting1-most serious2345-least seriousDiscipline problems at school/home1-most serious2345-least seriousAcademic issues1-most serious2345-least seriousDealing with peer pressure1-most serious2345-least seriousSibling rivalry1-most serious2345-least seriousAdoptive or Foster Children1-most serious2345-least seriousStepchildren1-most serious2345-least seriousFAMILYHusband and Wife1-most serious2345-least seriousSingle Parent1-most serious2345-least seriousConflict within the family1-most serious2345-least seriousExtended family1-most serious2345-least seriousCommunicating1-most serious2345-least seriousBeing a caretaker1-most serious2345-least seriousConflict outside the family1-most serious2345-least seriousCIRCUMSTANTIALStress and anxiety1-most serious2345-least seriousGrief or loss1-most serious2345-least seriousDivorce or separation1-most serious2345-least seriousFeeling isolated1-most serious2345-least seriousFeeling overwhelmed1-most serious2345-least seriousIllness or disability1-most serious2345-least seriousOtherWORK-RELATEDBalancing work and family1-most serious2345-least seriousEmployment1-most serious2345-least seriousDebt1-most serious2345-least seriousBudgeting1-most serious2345-least seriousConflict at work1-most serious2345-least seriousFinances1-most serious2345-least seriousPlease tell us how your experiences can helpIMPORTANT* I Agree To reduce potential liability for me, For The Family, and affiliated organizations, I agree to a confidential background screening if it is deemed necessary. I understand that For The Family reserves the right to limit participation accordingly. However, no details will be divulged to any other person, or kept on file.
