Marriage Mentor Request Form

Both spouses must fill out and submit a request form separately to begin the mentoring process.
 
 
 
 
 
Faith Background

Please select one option.
 
 
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About You

 
 
 
 
 
 
 
 
 
Marital Status

 
 
Remarried Couples

 
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Please select one option.
 
 
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Children

 
 
 
 
Payment

There's a $50 fee that will cover the cost of your material. Please ensure that ONE of the forms you fill out for this request has a payment submitted with it.
 
Mentee Agreement

By selecting the "I agree" button below, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. By selecting "I agree" you consent to be legally bound by this agreement's terms and conditions.
I understand that the Mentor Couple we meet with are not professional counselors, but volunteer marriage mentors who agree to share their life experiences with us in an effort to help us strengthen our marriage. I understand that we are responsible for the state of our marriage throughout the mentoring sessions or any time thereafter. I will allow Dare to be Different and LAVC leaders to access our personal information. All data collected by Dare to be Different will only be used as a quality control measure and will not be shared at any time with other parties.
Please select all that apply.
 
 
 
 
 

Description

Both spouses must fill out and submit a request form separately to begin the mentoring process.