The Puddle Project Mentee Application Form (Mother)

The Puddle Project Mentee Application for Mother

Please complete, submit and save a copy for yourself. (Enter N/A to any field that is required, yet it doesn't apply to you.)
Section 1. Email Address
Email*
Student School email address
Section 2. Personal Information
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail*
example@example.com
Mobile Number*
Who lives in the same house with you? *
How do you prefer to be contacted?*
Are you currently pregnant?*

YesNo
If you answered yes, Do you parents know you are pregnant?*

YesNo
If you have already delivered your baby, what is the name of the baby, gender, date of birth and age of your baby (include other children and gender also)?*
If you are pregnant, what is your due date?*
mm/dd/yyyy
What is your greatest need that you currently have? (Ex., books, diapers, time management, etc.)*
What are the names of your doctor(s)?*
Which hospital provides you services?*
You are required to meet with your Mentor at least one hour per month for this program. Please specify the best times that you are available to be Mentored. *
We are piloting Virtual Mentoring (because of the Pandemic/COVID-19) when in-person meetings are not possible. Do you have a device that will support this type of meeting?*
If you have a device that supports Virtual meetings, would you be willing to use this option with your Mentor?*

YesNo
Can you suggest an alternate place in the community to meet your Mentor if you can not connect during school or after school hours?*
Section 3. Personnel Information regarding the Father of the baby.
Is the Father of the baby interested in being a part of the Mentorship program?*

YesNoNot sure
Father's Full Name*

First NameLast Name
Father's Cell Phone Number
Please enter a valid phone number.
Father's Email Address
example@example.com
Section 4. School and/or Work Information
What high school are you currently attending?*
What year are you in high school?
(Please indicate Freshman, Sophmore, Junior, or Senior.)
Who should we contact at your school (counselor, principal, etc.)? *
Which classes are you currently enrolled it at school?*
What are your special interests, skills, or talents?*
Which extracurricular activities are you involved in?*
What is your future career choice?*
Are you currently employed?*

YesNo
If yes to employment, where are you employed and how many hours do you work each week? *
Thank you for completing your application. We will be in touch soon.
Should be Empty:

The Puddle Project Mentee Application for Mother

Section 1. Email Address

Section 2. Personal Information

Section 3. Personnel Information regarding the Father of the baby.

Section 4. School and/or Work Information

Thank you for completing your application. We will be in touch soon.