NICE Youth Mentorship Application Form

NICE Youth Mentorship Application

Use this form to enroll student(s) for one-on-one mentoring
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Country of Origin*
Parent Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
School Enrolled*
Grade*
Language(s) Spoken*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide verification of eligibility if you are able. (Ex: BIO, I-94, VISA)

Cancelof
- Youth Mentorship Program: Parents/Guardian Consent form
- I, the parent or legal guardian for child's name hereby give my permission for my child to participate in the Youth Mentorship Program with a mentor at least four times a month for a duration of four months, which can be extended.
- Initial Here   I understand that the program involves one-on-one time with mentors who have been selected and trained from Universities, Civic Organizations, New American Communities, and Corporations based in Nashville, Tennessee.
  
  Initial Here   I understand that participation in the Program may include transportation of my child by their mentor, and at least two adults must be present in the car.
  
  Initial Here   I understand that some meetings between my child and their mentor will be held at my residence, outside of school, or over a virtual medium.
  
  Initial Here   I understand that it is my responsibility to contact NICE staff as soon as concern arises.
- (Signature of Parent/Guardian)
  
  Clear
- (Signature of interpreter if applicable)
  
  Clear
- (Printed name of Parent/Guardian)
- (Printed name of interpreter)
- Date
  
  MonthDayYear
  Date
- Date
  
  MonthDayYear
  Date
- Should be Empty: