Special Fathers Network Enrollment Form Enroll in the Special Father’s Network To enroll, please complete the online form below. ALL INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL. Step 1 of 3 33% CONTACT AND PERSONAL INFORMATIONPlease choose one of the following options:*I would like to be a mentor. I have 5 years or more raising a special needs child.I am seeking a mentor father. I have a special needs child.Name* First Last Address* Street Address Address Line 2 City State ZIP / Postal Code Date of Birth*Marital Status* Married Single Divorced Home Phone*Cell PhoneWork PhonePreferred time of day to be contactedMorningAfternoonEveningEmail* CHILD(REN)Please list the names and birthdays of your children. Click on the plus symbol to add more fields.*Child's First & Last NameBoy/GirlChild/Step Child/GrandchildDate of BirthSpecial Needs Child?If Yes, Describe Special Need BoyGirlChildStep ChildGrandchildYesNo Questions or Comments?To the best of my knowledge the above information is accurate and correct and I have not omitted any information that would misrepresent my situation.* Yes EMPLOYER INFORMATIONEmployerTitleWork Address Street Address Address Line 2 City State ZIP / Postal Code NameThis field is for validation purposes and should be left unchanged.