Mentee Application

Mentee Application
All sections of this application must be completed. Parents, please review this application prior to signing.
PART I – GENERAL INFORMATION
Print Clearly
Full Name

First NameLast Name
Date of Application:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email Address:
example@example.com
Date of Birth:

MonthDayYear
Date
Gender:
Age:
Parent/Guardian Full Name:

First NameLast Name
Parent / Guardian's phone number if different from above:

Area CodePhone Number
What languages other than English do you speak?
School Name:
Grade:
What is your favorite subject?
What is your least favorite subject?
What activities, clubs, sports, etc. are you involved in?
PART II – INTERESTS/PREFERENCES/FAVORITES
A. List, in order of preference, the jobs/professions you have been thinking about for yourself:
B. Please tell us what you hope to gain from this mentoring program. (For example: build new relationships, gain new college/career goals, learn about what to expect in high school and in college, how to do better in school.)
C. What do you want to learn from your mentor?
D. What do you like to do the most in your free time?
PART III – INTRODUCTION

Please introduce yourself to your mentor by writing a little bit about yourself. You can start by telling them your name, how old you are, where you live and what you expect to gain from this experience. You can also let them know what your plans are after high school, what college or university you would like to attend and why, as well as how you plan to prepare yourself to meet your goal. We will share this information with your mentor. (Please upload your essay).
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PART IV – PHOTO RELEASE

I understand that Mentor-Mentee Program may attract attention from the media and there is a possibility that youth will be photographed/videotaped during their experience.
I grant permission to photograph/videotape my son/daughter.

YesNo
PART V – ADDITIONAL INFORMATION
Does your child require any special accommodations due to medical limitations, disability, dietary constraints or other restrictions? Please explain.
Does your child require any special accommodations due to medical limitations, disability, dietary constraints or other restrictions? Please explain.
PART VI – MENTEE PARENT/GUARDIAN CONSENT FORM

Permission to participate in the MIPO, Inc. Mentor/Mentee program
I, __________________________________________, give my son/daughter permission to participate in the MIPO Mentor/Mentee Program and I hereby agree to all of the above authorizations.
Signature of Mentee

Clear
Date

MonthDayYear
Date
SIGNATURE OF PARENT/GUARDIAN

Clear
Date

MonthDayYear
Date
Making the Impossible Possible, Inc.

P.O. Box 360171

Brooklyn, NY

11236-0171

631-954-1920

347-523-2196

www.mipoinc.org

info@mipoinc.org
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Mentee Application

PART I – GENERAL INFORMATION

Print Clearly

PART II – INTERESTS/PREFERENCES/FAVORITES

PART III – INTRODUCTION

PART IV – PHOTO RELEASE

PART V – ADDITIONAL INFORMATION

PART VI – MENTEE PARENT/GUARDIAN CONSENT FORM