Program Application

Thank you for your interest in participating in the MDTMT program.

Please complete the application. We'll be in contact with you to inform you about the status of your application upon submission.

Name

First Name

Last Name

Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone 1

Enter your child's best contact number.

(###)

###

####

What school do you currently attend?

Parent Name 1

First Name

Last Name

Parent 1's Telephone Number

(###)

###

####

Parent Name 2

First Name

Last Name

Parent 2's Telephone Number

(###)

###

####

Emergency Contact

First Name

Last Name

Emergency Contact Number

First Name

Last Name

Getting To Know You

Tell us about yourself:

Write a paragraph about who you are, what you enjoy doing, and your favorite things.

Why do you want to be a part of My DaddyTaught Me That?

Please list at least three reasons you'd like to join our program.

Parent information

Tell us about your child or the applicant.

Please describe your applicant, let us know of any specific areas you'd like us to focus on with him, and why you believe he needs to be in participate in MDTMT's program.

PLEASE BE CERTAIN THAT YOUR ANSWERS ARE TRUE AND CORRECT BEFORE CLICKING THE SUBMIT BUTTON.

By submitting this application you also agree to give your child permission to attend off-site field trips and you give consent for your child's image to be published in any print, photographic, video, web or other media (including the MDTMT website).

Yes, I agree.

Program Application

Thank you for your interest in participating in the MDTMT program.

My Daddy Taught Me That
@KL TRAINING IMPACT CENTER

3 HUNT HILL PLACE
Asheville, NC 28801