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Application of Interest

Parent/Guardian first and last name(Required)

First Last

Parent/Guardian best contact number

Parent/Guardian email address(Required)

City of residence

Relationship to Youth

Youth's first and last name(Required)

First Last

Youth's Age?

Youth Age Group(Required)

Please select all of the following

I hereby grant permission for Take My Hand Girl to make contact with my child and conduct a personal interview for the purpose of applying to the program.

I understand that basic information about my child will be anonymous, shared with a prospective advisor to aid in determining a suitable match. Once selected my and my child’s identity and other relevant information will be shared with the advisory board on an as needed basis.

I am committed to supporting my child by way of transportation to in person meetings and events at a minimum of one time per month (25 mile radius-Beaumont, Texas)

I understand and agree that this is an expression of interest and not a commitment. The application will be sent to you via email during the enrollment process.

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Application of Interest

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