Your Name
Your Phone number
Your Email address
Your county Baringo Bomet Bungoma Busia Elgeyo-Marakwet Embu Garissa Homa Bay Isiolo Kajiado Kakamega Kericho Kiambu Kilifi Kirinyaga Kisii Kisumu Kitui Kwale Laikipia Lamu Machakos Makueni Mandera Marsabit Meru Migori Mombasa Murang'a Nairobi City Nakuru Nandi Narok Nyamira Nyandarua Nyeri Samburu Siaya Taita Taveta Tana River Tharaka-Nithi Trans Nzoia Turkana Uasin Gishu Vihiga Wajir West Pokot
What do you hope your teen to gain or learn in this program?
Where did you learn about this program adopt and mentorme or about Servekom Teenovation Centre? Fellow Parent My Teen Teachers Social Media Internet
Would you recommend this program to another parent/teenager? Yes No Maybe I prefer not to say
Any other thing you would wish to share with us?
TEEN'S PERSONAL INFORMATION
Your Full name
Your gender Male Female I prefer not to say
Your email
Your Phone number
Your Current age
Your current education level Primary School -Upto Grade 6 Secondary School - Including Junior and Senior School Tertiary -University, Colleges and TVET etcs
Name of your current institution
What are your expectations about this program
Do you feel comfortable to speak in group setting? Yes No
Where did you hear about this program or Servekom Teenovation Centre? Parent Friend Social Media Internet Teacher
Would you refer this program to your fellow teenager to also learn and gain from the leading mentors Yes No Maybe I prefer not to say
Do you have any questions for us? (optional)
Parent Consent
I give permission for photos/videos of my teen to be used in program-related media.
