The Tobin Teen Mentorship Program
Mentee: Grades 6-8
Mentees Name
*
First Name
Last Name
Parent's Cell Phone
*
Please enter a valid phone number.
Parent's Email
*
example@example.com
Mentee's Date of Birth
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Grade
*
6
7
8
School
*
I've filled out the one-time teen info form (CTeenAtlanta.com/teeninfo)
*
Yes
Please tell us a bit about your teen, as well as what activities interest them and what subjects you’d like them to be mentored in:
*
What subjects and electives interest your teen?
*
Math
Science
History
Judaics
English
Hebrew
Chess
Other (Please specify)
Mentee
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Payment for all twelve sessions
$
360.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Payment Plan Option: Payment Plant/Scholarship - as discussed with Talya:
$0.00
Submit
Should be Empty: