Mentee Application

Cultivating Leaders Mentoring Program

Mentee Application Form
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Home Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Gender*
School*
Current Grade*
Race or Ethnicity*
Name of Parent or Guardian*

First NameLast Name
Parent Number*

Area CodePhone Number
Parent Email*
example@example.com
General Information
Did you have a mentor before through our program? *

YesNo
Did you apply before and not receive a mentor? *

YesNo
How did you hear about Cultivating Leaders Mentoring Programs?*

Social MediaTeacherFriendGuidance CounselorFamily MemberCurrent/Previous Student
What Cultivating Leaders program are you interested in?*

Visionary LeadersY-ME Youth Mentoring & EmpowermentSTEM Mentoring Program
Why do you want a mentor?*
What would like you to see in your mentor?*
Describe two things that you are good at:*
Name three words that describe you:*
What are some things that you would like to change about yourself?*
What kind of activities would you like to do with Cultivating Leaders Mentor Program?*
What clubs, activities, or sports you are involved in? What are the time commitments for each?*
Is there anything unique that you would like to describe about yourself that may help us find the best mentor for you?
Your Preferred Mentor

MaleFemale
Required Signatures
Cultivating Leaders will do our best to match you with a mentor who has similar interests and who we think would be a good role model for the upcoming year. You should meet with your mentor 1-2 hours a week. Your mentor will provide you with the times and dates of when you both will meet.

I certify to the best of my ability that the information provided in this application is true and accurate. I also understand that misinformation knowingly provided here and on subsequent application form, is ground for dismissal.
Student Signature*

Clear
Date*

MonthDayYear
Date
Parent / Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Cultivating Leaders Mentoring Program

General Information

Required Signatures