Summer 2021 Virtual Mentoring Program
Student Application
PERSONAL INFORMATION:
first & last name
*
Address: (Please include city, state, zip, & apt. number if applicable)
*
Email
example@example.com
Phone Number
-
Area Code
Phone Number
may we send you text messages at this phone number?
Yes
No
Age:
*
Gender:
*
Male
Female
Ethnicity:
*
School Attended:
*
Grade:
*
Extracurricular Activities:
*
WAIVERS & CONSENT
See parent waiver/consent form on the website. A signature will be required and possible verification may be requested at a later date.
Please initial below if you agree to the above terms and conditions of the MentorMe program
Parent Initials:
*
Application Questionnaire
To be completed by the student/mentee
What do you normally do during the Summer?
*
What work or "other" commitments do you currently have?
*
Do you have transportation?
*
Yes
No
Have you participated in any kind of group activity before outside of school: church, community, etc.?
*
Yes
No
What motivated you to apply to this process? What do you hope to gain from this experience?
*
Please Note: A verbal interview will also be scheduled and conducted via Zoom with the applicant, parent, and both MentorMe facilitators.
Please verify that you are human
*
Submit
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