THE STANDARD CLUB

Parent / Legal Guardian Full Name

Parent / Legal Guardian Email *

Parent/Legal Guardian Phone *

Address

Street Address *

City *

State *

Country

Postal Code *

Student First Name *

Student Last Name *

Date of birth *

Program open to ages 11-15

School Name

Grade At Time of Enrollment *

T-Shirt Sized (Men's Siing) *

Medical Information *

Medication information is only needed if the student will need to self-administer while in our care. Volunteers will observe but are not licensed to administer pharmaceuticals.

Is your child currently experiencing any challenges (emotional, academic, behavioral, social, etc.) that we should be aware of? *

This information helps the mentors provide targeted support

Desired City, If Not Listed Above

If you are interested in starting a new chapter in your city, complete the information below.

Interested in Starting a New Chapter In Your City? *

*Background check is mandatory for all Chapter Leaders, Mentors - anyone working directly with the students.

Interested in supporting The Standard Club mission? Select all that apply:

*Background check is mandatory for all Chapter Leaders, Mentors - anyone working directly with the students.

Alternate Contact: *

Used only in the case of emergency when the primary contact cannot be reached.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply. Reply OUT to opt-out.

By submitting this form, I understand that this is an interest/pre-enrollment form and does not guarantee program placement. I agree to be contacted with additional details, orientation info, and next steps.

Parent/Legal Guardian Signature *

Clear

Current Date *