Mentee Application

ACTION, Inc. Mentee Application

Personal Information
Mentee’s Name *

First Name Last Name
DOB *

Month Day Year
Date
Age *
Gender *
Ethnicity
Guardian’s Name (1) *

First Name Last Name
Relationship to youth *
Guardian’s Name (2- if applicable)

First Name Last Name
Relationship to youth
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email
example@example.com
Name of School *
Current Grade *
Emergency Contacts - Please include Name, Relationship, & Phone number *
Please note that these individuals will be contacted in case of an emergency if primary guardians (listed above) cannot be reached. They will also be able to pick up your child from ACTION, Inc. events and outings.
Please list the names, ages, and relationships of all individuals in mentee’s household *
Please indicate if not applicable
Please answer all of the following questions as completely as possible. The answers to these questions will aid us in matching you with a mentor.
Why does your child want to participate in a mentoring program? *
Briefly describe your expectations of the mentoring program. *
Please describe your child’s personality using at least 3 words. *
What does your child enjoy doing for fun? *
Is your child available to meet with a mentor a minimum of one hour per week? *

Yes No
If applicable, please explain any scheduling issues that you may have.
Describe your child’s school performance including grades, homework, attendance, behaviors, etc. *
Does your child have friends? Please describe his/her friendships. *
Is your child currently having problems either at home or at school? If yes, provide details. *
Has your child experienced any traumatic events (i.e. death in the family, abuse, divorce)? If yes, please provide as much detail as you feel comfortable sharing with us. *
Can you provide any additional background information that may be helpful in matching your son/ daughter with an appropriate mentor? (Anything that we should be aware of that could be a trigger for you or your child.) *
Do you have any religious preferences you would like for us to take into consideration?
Is there anyone your child should not have contact with while participating in our program?
Select at least two social issues that you would like to be addressed with your child throughout our program. *

School Attendance High School Completion Access to Higher Education Alcohol/drug use Poverty relief Job Training Child Abuse Sex Education Gun Violence Bullying Lack of Adult Supervision Social Media Racism/ Discrimination Juvenile Crime Rates Child Care/ Teen Recreation
Medical History
Name and phone number of primary care physician
If no PCP, please indicate where you are most likely to receive medical care
Medical Insurance Provider & policy number
Does your son/daughter have any physical problems or limitations? *

No
Is your son/daughter receiving treatment for any medical issues? *

No
Is your son/daughter currently taking daily medication? *

No
Does your son/daughter have any known allergies or adverse reactions to medications? *

No
Does your son/daughter have any known allergies or reactions to anything, other than medications? *

No
Is your son/daughter currently seeing a counselor or therapist? *

No
By signing below, I attest to the truthfulness of all information listed on this application and agree to all of the above terms and conditions. I give my informed consent and permission for my child to participate in ACTION, Inc's Mentoring Program and its related activities. *

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ACTION, Inc. Mentee Application