YPIA Mentee/Youth Application

YPIA Mentee/Youth Application

Please fill out the mentee/youth information below and submit so that we may connect you (the mentee/youth) to the mentorship opportunity within Young People in Action (YPIA) that best suits your needs and interests. We look forward to hearing from you!
Mentee/Youth Name: *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mentee E-mail*
Mentee Phone*
Work Phone
What is the best form of contact?*

EmailPhone CallTest MessageOther
Mentee Birth Date*

MonthDayYear
Date
Mentee Gender*
Self-described Gender
Race/Ethnicity*
Self-described Race/Ethnicity
Religious Affiliation (if any)
Do you speak any other languages besides English?*

YesNo
What other languages?

Emergency Contact Information
1. Parent Name:*

First NameLast Name
2. Parent Name:*

First NameLast Name
Relationship to Mentee*
Contact Phone*
Parent e-mail*
example@example.com
Applicant Education

Please enter your current education information.
Are you currently in school?*

YesNo
Please list the name of the school(s) and your major(s):
Expected Date of Graduation

MonthDayYear
Date
What is your highest level of education completed?
Please list any and all areas of interest and/or ability:*

Leadership DevelopmentCommunity ServiceSocial ActivitiesPersonal GrowthMindset TrainingCreative/Art ActivitiesOther

Verification & Submission
How did you first hear about YPIA?*

Friend/Family/AcquaintanceSearch Engine (e.g. Google, Yahoo, etc.)Social Media (e.g. Facebook, Instagram, etc.)AdvertisementYPIA Staff MemberOther
Please verify that you are human*
Should be Empty:

Applicant Household Information