STUDENT APPLICATION Student Name * First Name Last Name Date of Birth MM DD YYYY Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Grade * Please select one or more options 3rd 4th 5th Other School Name * Parent/Guardian Name * Phone * (###) ### #### Email Address * Number living in household (please list name, age(s) & relationships) * What school/community activities does your child participate in? * What special interests or hobbies does your student have? * Please state any specific problems your student has at home or in school (anger issues, medical problems, please explain)? * Do you have any mentor preferences? * Ex: Extroverted, loves sports, artistic, race, age etc. Thank you so much applying. Someone from the Blueprint 58 team will be in touch soon with next steps. We are looking forward to having you as a part of the Blueprint 58 community!
