Child Enrollment Information Request

If you are human, leave this field blank.

Are you a single parent or grandparent raising children? *

Yes

No, Children's Mentoring Connection generally serves only single-parent or grandparent households.

Parent/Guardian *

Address *

City *

Zip *

Phone *

Email Address *

How Did You Hear About CMC? *

First Child Information

Child's Name *

Date of Birth *

Gender *

School *

Second Child Information

Child's Name

Date of Birth

Gender

School

Third Child Information

Child's Name

Date of Birth

Gender

School

Website/URL

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