Mentee Application 2022

Thank you so much for being so interested in becoming a mentee with Mentoring Mentors Inc. This mentee experience encourages youth to embody: leadership, integrity, virtues, a passion for serving within the community, the importance of long-lasting positive relationships, and working together.

First Step: Please complete all questions on the application as best as possible. If you are under the age of 18, your parent must complete the form.

Second Step: Schedule face to face in-person interview using the following link:
- https://calendly.com/mentoringmentorsinc/60min
Third Step: Commit to do better and build relationships.

Remember, if you try, you'll always win, but if you don't try, you'll always lose.

This form must be filled out electronically. Handwritten applications will not be accepted.

ittp://www.Mentoring-Mentors.org
Mentee Application
1. Mentee Name*
2. Mentee Home Address*
3. Mentee City and State *
4. Mentee Zip Code*
5. Mentee Date of Birth*

MonthDayYear
Date
6. Mentee T-Shirt Size*

XSSMLXLXXL
7. Name of School and Student School ID Number (Found on Report Card)*
8. Mentee Sex*

FemaleMalePrefer not to sayOther:
9. Mentee Sexual Orientation*

HeterosexualHomosexualBisexualGayLesbianQuestioningOther
10. Mentee Ethnicity*

African AmericanAmerican Indian/Native AmericanAsian/Pacific IslanderCaucasianHispanic/LatinoMulti-racialOther:
11. Mentee illnesses (Check all that apply)*

AllergiesDiabetesAsthmaRheumatoid ArthritisNoneOther
12. Challenges/Behavior/Other (Describe below. If none, type N/A)*
13. Mentee has a history of: (Check all that apply)*

Emotional AbusePhysical AbuseSexual AbuseSubstance AbuseNoneOther
14. Would you like your Mentee to receive counseling services*

YesNo
15. Household Income Level*

$10,000 - $24,999$25,000 - $49,000$50,000 - $74,999$75,000 - $99,999$100,000 - $149,000Other
16. Household Family Structure*

Single - Parent FamilyTwo Parent FamilyGuardianFoster CareGroup HomeKinship Care ( Non - Parental Relationship)Other
17. Mentee Interests (Check all that apply)*

Arts/CraftsBoard GamesCommunity Service/ VolunteerismComputer/Video GamesCooking/Eating OutCultural EventsCultural Events: Concerts
Cultural Events: MuseumsCultural Events: TheaterDanceDramaFashionMoviesMusicMusic: Listening to musicMusic: Playing an instrumentMusic: SingingOutdoor ActivitiesOutdoor Activities: BikingOutdoor Activities: Boating/CanoeingOutdoor Activities: Fishing/HuntingOutdoor Activities: HikingOutdoor Activities: Ice- SkatingOutdoor Activities: Rollerblading/SkateboardingOutdoor Activities: Running/ WalkingOutdoor Activities: Skiing/ SnowboradingPetsReadingShoppingSportsSports: Playing sportsSports: Playing BaseballSports: Playing BasketballSports: Playing CheerleadingSports: Playing FootballSports: Playing GolfSports: Playing GymnasticsSports: Playing HockeySports: Playing LacrosseSports: Playing Martial ArtsSports: Playing SoccerSports: Playing SoftballSports: Playing TennisSports: Playing Track FieldSports: Playing VolleyballSports: Playing Wrestling
Sports: Watching SportsSports: Watching BaseballSports: Watching BasketballSports: Watching CheerleadingSports: Watching FootballSports: Watching GolfSports: Watching GymnasticsSports: Watching HockeySports: Watching LacrosseSports: Watching Martial ArtsSports: Watching OtherSports: Watching SoccerSports: Watching SoftballSports: Watching TennisSports: Watching Track and FieldSports: Watching VolleyballSports: Watching WrestlingTravelTVWritingOther:
18. Mentee Primary Emergency Contact (Name)*
19. Mentee Primary Emergency Contact Relationship*

MotherFatherChildLegal GuardianFoster ParentStep-ParentOther
20. Mentee Primary/Parent Emergency Contact (Mobile Number)*

Area CodePhone Number
21. Mentee Primary/Parent Emergency Contact (Email)*
example@example.com
22. Mentee Secondary/Relative Emergency Contact (Name)*
23. Mentee Secondary Emergency Contact Relationship*

MotherFatherChildLegal GuardianFoster ParentStep-ParentOther
24. Mentee Secondary/Relative Emergency Contact (Mobile Number)*

Area CodePhone Number
25. Mentee Secondary/Relative Emergency Contact (Email)*
example@example.com
26. What grade is your student in?*
27. * We would like permission to collect the following information from school provider to help assist with supporting student: Report Cards, Grades Discipline Data, PBIS Data, Attendance, Standardized Testing

Results, IEP and Social & Emotional Screeners.*
Mark only one oval.*

YesNo
28. Please list the medical insurance provider (For emergencies only) *
29. Please list the medical insurance policy number (For emergencies only)*
30. * If your child is seriously injured is it okay for Mentoring Mentors staff to transport your child to the hospital? *
Mark only one oval.

YesNo
31. *I hereby grant Mentoring Mentors permission and the right to use photos/ photographs and video recording of my child on Mentoring Mentors website, publications, and promotional materials. *
Mark only one oval.*

YesNo
32. Do we have parent permission to collect grades from mentee

YesNo
33. Does your mentee have an individual education plan (IEP) for any learning disability? If so, please list their learning disability. If none, type "N/A" *
Date

MonthDayYear
Date
Parent or Guardian Signature

Clear
Should be Empty: