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CHILD ENROLLMENT APPLICATION for Climb

If you are interested in having your child participate in the LSS Climb mentoring program, please complete the fields listed below and click "Send Now" at the bottom of the page. If you would like to enroll more than one child, please complete a form for each person. Printed enrollment forms are available upon request.

If you do not receive a confirmation email within 48 hours confirming the application went through successfully, please contact LSS Climb at 605-444-7806.

FILL OUT THE APPLICATION To Enroll Your Child in Climb Mentoring

Contact Information

Child Gender
Country
Address Line 1
Address Line 2
City
State
Postal Code
Preferred contact method:
Does the child spend significant time at a different residence
Country
Address Line 1
Address Line 2
City
State
Postal Code
If the child is male, are they willing to be matched with a female volunteer?


Referral Information

How did you become aware of LSS Climb Program? Check as many as apply and describe below



Matching Information

My child would like to meet with a mentor the following days/times:

Thank you!

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