Boyz to Men Mentorship Group Application

Mentorship Application

Fill out the application below:
Personal Youth's Information
Name
Date

Month Day Year
Date
Parent/Guardian Name
Relationship to Youth
Other (please specify)
Street Address
City
State
Zip
Home Phone
Work Phone
Cell phone
Youths Date of Birth

Month Day Year
Date
Age
Gender
Ethnicity
Name of School
Grade
Emergency Contact Name
Phone Number
Application Questions

Please answer all of the following questions as completely as possible. If more space is needed, use an extra sheet of paper. The answers to these questions will aid us in the matching process.
1. Why do you/your child want to participate in a mentoring program?
2. Briefly describe your expectations of the mentoring program?
3. Is your child available to meet with a mentor a minimum of one hour per week?

Yes No
Please explain any particular scheduling issues that you may have.
4. Describe your child's school performance including grades, homework, attendance, behaviors, etc.
5. Does your child have friends? Please describe his/her friendships
6. Is your child currently having problems either at home or at school? If yes, provide details.
7. Has your child experience any traumatic events (i.e. death in the family, abuse, divorce)? If yes, please provide details.
8. Can you provide any additional background information that may be helpful matching your son/ daughter with an appropriate mentor? (Anything that we should be aware of that could be a trigger for you or your child.)
9. Do you have any religious preferences you would like for us to take into consideration?
10. Is there anyone your child should not have contact with?
Medical History
Name of Primary Care Physician
Phone Number
Does your son/daughter have any physical problems or limitations?

Yes No
Is your son/daughter receiving treatment for any medical issues?

Yes No
Is he/she currently taking any type of medications?

Yes No
If yes, please explain
Does your son/daughter have any known allergies or adverse reactions to medications? If yes, please explain does your son/daughter have any emotional issues right now? If yes, please explain
Is your son/daughter currently seeing a counselor or therapist?

Yes No
If yes, please explain
Please read this carefully before signing: We appreciate you and your child's interest in his/her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their son/ daughter to participate in the mentoring program. After receiving this completed application from you, we will evaluate the information and send you a letter letting you know if your child has been accepted into the mentoring program. Much of the information that you supply in this application packet will be used to match your child with an appropriate mentor. Therefore, the mentoring staff may, at times, need to access and share this information with prospective mentors and other parties when it is in the best interest of the match. However, we do not reveal names until there is an initial interest from the mentee, parent/guardian, and mentor based upon anonymous information provided
INITIAL each of the following ____ I give my informed consent and permission for my child to participate in the Boyz to Men Mentoring Program and its related activities.____ I agree to have my child follow all of the mentoring program guidelines and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship. ____ I hereby acknowledge that my child may be transported by his/her mentor while participating in the mentorship program, and that such transportation is voluntary and at his/her own risk. ____ I release the Boyz To Men Mentoring Program of all liability of injury, death, or damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined. I understand that I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of this application being processed:

• Signed application

• Contact and Information Release Form

• Youth Mentee Guidelines/Instructions Form

By signing below, I attest to the truthfulness of all information listed on this application and agree to all of the above terms and conditions.
Parent/Guardian Signature Date

Clear
Parent/Guardian Signature Date Please submit this application and all items listed above to Boyz to Men Mentoring Program
(To Be Completed by the Parent/Guardian)
Youth's Name
Date

Month Day Year
Date
I hereby grant permission for the Boyz to Men Mentoring Program to make contact with my child and conduct a personal interview for the purpose of applying to be a mentee. Further, I understand that basic information about my child will be anonymously (without names) shared with a prospective mentor(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my and my child's identity and other relevant information will be shared with the mentor to the extent it aids in facilitating a successful match.
Parent/Guardian Signature Date

Clear
Parent Name
Address
City
Zip
Home Phone
Cell Phone
Boyz to Men Mentoring Program

YOUTH MENTEE GUIDELINES/INSTRUCTIONS (To Be Completed by the Youth)

1. be dependable and punctual! If you will be late or absent, please notify the mentor as soon as possible.

2. Never put yourself into situations that could be perceived as inappropriate. Meet in public places as much as possible. Examples- - never be in a home alone with your mentor. Never be in a bedroom or bathroom with you mentor.

3. Absolutely NO photos or sharing of information can be shared on social media

4. Refer concerns to your guardian/contact person.

5. Never take any kind of medication (i.e., aspirin) from a mentor.

6. Smoking, drinking or drug use is not permitted while with a mentor.

7.Respect mentors privacy. When meeting and talking with mentor in public, avoid talking about private matters where others can hear.

8. Respect cultural and social differences and religious beliefs. Do not try to change them, but instead accept them as they are. Avoid imposing your own upon them.

9. Do not travel with your mentor without written consent from your parent/guardian.

10. Make any promises sparingly and keep them faithfully.

11. Mentor/mentee assignments may be changed if either the mentor or mentee request it.

12. Please do not carry weapons of any kind when spending time with your mentor.
Youth Mentee's Signature Date

Clear
Parent/Guardian's Signature Date

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Mentorship Application

Personal Youth's Information

Application Questions

Medical History