2. Please complete all required information below in order to register to our Mentors in Blue Forum.

   This forum is exclusively for New Rochelle Youth in middle school and high school.

4. Student Information
6. Student's Name*
8. Age*
9. Gender*
10. Pronoun
12. Home Address*
13. Apt*
15. Zip Code
16. Home Phone*
17. Ethnicity/Race
19. Email*
21. School as of January of the current year:*

    Please check one:

    1. NRHS
    2. IEYMS

    1. ALMS
    2. Other
23. Name of School if selected other in previous question
25. Parent/Guardian Information
27. Parent/Guardian #1 Name*
28. Parent/Guardian #1 Cell Phone*
30. Parent/Guardian #2 Name
31. Guardian/Parent # 2 Cell Phone
33. Email*
    For notification purposes, please provide an email to be used to contact you.
35. EMERGENCY CONTACT INFORMATION (Person OTHER than parent/guardian required for emergency contact)
37. 1st Emergency Contact's Name*
38. Phone*
40. Relationship to Child*
42. 2nd Emergency Contact's Name*
43. Phone*
45. Relationship to Child*
47. Choose One or More*

    Please Select what program or event you would like to sign up for. You may choose more than one.

    1. Mentors in Blue Forum - March 22 4pm - 6pm - City hall
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field