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 AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone NumberE-mail* CAPTCHAI 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. Consent* I consent to my submitted data being collected and stored
