Participant/Mentee Intake Form

At Empowerment Lab, Mentees or Participants are middle school or high school aged,

and participate in all activities offered, including advising administrators on programming, and helping to design the space.

Name *
Name
Diagnosis *
What is your PRIMARY diagnosis?
Do you have physical limitations we should know about?
Please let us know what you enjoy doing in your free time!
How did you hear about Empowerment Lab? *