2022-2023 Mentee Profile Form

Welcome to the Latino Youth Leadership Academy Mentoring Program

Bienvenido al Programa de Mentoría de la Academia de Liderazgo Juvenil Latino
I am interested in having a 1-to-1 mentor: *

Yes No
I am committed to communicating with my mentor virtually or face to face. *

Yes No
Student Information

Informacion del Estudiante
Student's name / Nombre y Apellido *

First Name Last Name
Student's cell phone number / Numero de telefono *

Area Code Phone Number
Student's email / Correo electrónico *
Student's home address / Direccion *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
County / Condado *
Student's birthday *

Month Day Year
Student's gender / Genero *

Female /Femenino Male / Masculino Nonbinary / No binario Decline to State / Prefiero no responder
Primary Language / Idioma Principal

English / Ingles Spanish / Espanol Other/ Otro
English Proficiency / Dominio del ingles *

Little / Poco None / Ninguno Moderate / Intermedio Fluent / Fluido Native / Nativo
Is this your first time at the LAA? Es su primera vez en el LAA? *

Yes / SI No / No
Grade / Grado *
Student ID number / Numero de estudiante *
School / Escuela *

Meadowcreek High School Sequoyah Middle School Chamblee High School Cross Keys High School Lakeside High School Lilburn Middle School Berkmar High School Berkmar Middle School Radloff Middle School McClure High School Other
Sabes lo que es la universidad?

Si No
Conoces los pasos necesarios para aplicar a la universidad?

Si No
Conoces los pasos necesarios para pagar la universidad?

Si No
Sientes que sabes como encontrar la mejor carrera para ti?

Si No
How did you hear about the LAA? *

Word of Mouth (Family & friends) / Familia y Amigos) LAA Internal Referral / Referido de otro departamento del LAA Other Agency / Otra agencia Social Media / Redes sociales Television / Television LAA Website / Pagina de Internet School / Escuela Email / Correo electrónico Other
Nationality / Nacionalidad *
Race / Raza *

Mixed Race / Mestizo White / Blanco Asian / Asiático African American or Black / Afroamericano American Indian / Indio americano Native Hawaiian / Hawaiano Nativo Unknown / Desconozco Declined to State / Prefiero no responder Other
Are you Hispanic or Latino descent? / Eres hispano o descendiente Latino? *

Declined to state / Prefiero no contestar Yes / Si No / No Other
Student Mentee Information
Is this your first time having a mentor with the LYLA Program?

Yes No
Ideal Job/Career
Ideal College/University
What are your favorite subjects in school? Choose all that apply:

Language Arts Social Studies Math Science Foreign Language Fine Arts Music Athletics Business
How would you describe your personality/interests? Choose all that apply:

Outgoing or Sociable Sports Fan Introverted or Reserved Lover of learning new things Thrill Seeker Health-Conscious Foodie/Home Chef Athletic Nature Enthusiast Pet Person Artistic/Maker
Please tell us about your hobbies and other interests. How do you like to spend your free time?
What are you most passionate about/ what is something that is really important to you? (This could include personal values, community issues, etc.)
What else do you look for in a mentor? Or what do you need/want the most help with? (Characteristics, personality, common interests/hobbies, etc.)
***Other*** Please specify anything else you would like us to consider when matching you with a mentor. (For example: DACA or Undocumented, LGBTQIA+, etc.)
Parent Information

Informacion de Madre o Padre
Parent/Guardian's name *

First Name Last Name
Parent/Guardian's cell phone number *

Area Code Phone Number
Parent/Guardian's email *
Immigration Status / Estado Migratorio *

Unknown / No se Prefiero no contester / Declined to state Ciudadano estadounidense / US citizen Residente estadounidense / US resident Indocumentado / No autorizado / Undocumented / unauthorized Estado de Protección Temporal / TPS Asilado / Asylee Refugiado / Refugee Daca / Daca Visa U / U visa Visa T / T visa Autorizado para trabajar en U.S. / Work authorization in the U.S. Identificación fiscal / Tax id Estudiante / Student Otro / Other
Monthly Household Earned Income, including all family members currently working (gross) / Ingreso total mensual del hogar, incluyendo todos los familiares que trabajan en el hogar (bruto) *

No earned Income $ 1 - $ 499 $ 500 - $ 999 $ 1,000 - $ 1,499 $ 1,500 - $ 1,999 $ 2,000 - $ 3,499 $ 3,500 or more Client declined to answer Unknown Other
Household size (including yourself) / Cuantas personas en total viven en su hogar include (a) usted? *
Number of Adults / Numero de Adultos *
Number of Children (under 18 years old) / Numero de Ninos (menores de 18 anos) *
Employment Status / Tiene empleo? *

Full time / Tiempo completo Part-time / Medio Tiempo Temporary Work / Trabajo temporal Unemployed / Desempleado Contractor (Self Employed) / Contratista Homemaker / Ama de casa Exempt / Exento Declined to answer / Prefiero no responder
Marital Status / Estado Civil *

Single (Never Married) / Soltero (a) Married / Casado (a) Separated / Separado (a) Divorced / Divorciado (a) Widowed / Viudo (a) Domestic Partner / Conviviente Declined to state / Prefiero no responder Other
Transportation / Transporte *
Highest Education Completed / Nivel Mas alto de Educación *

Primary School (8th Grade or less) / Escuela primaria o incompleta 0-3 years / 0-3 anos Some High School / Escuela secundaria o incompleta Highschool Diploma or GED / Diploma Secundaria o GED Associate's Degree / Grade de Asociado (a) Technical School or certificate / Colegio tecnico o certificado University / Universidad Master's Degree / Maestria None / Ninguna Decline to state / Prefiero no contestar Other
Select LAA Services you would like to receive

Seleccione en que servicio esta interesado
LAA Internal Referrals

English classes / Clases de ingles Digital and computer classes / Clases de computación Spanish classes / Clases de español Employment and Job Training / Empleo y entrenamientos Programa para Latinas emprendedoras Bank profession training: Unidos in Finance / Capacitación para trabajo en banca SNAP and Medicaid / Estampillas y Medicaid Victims of Violence / Víctima de Violencia Financial Assistance Rent & Utilities / Ayuda financiera para pago de rental o utilidades Food Pantry / Despensa de comida COVID Resources / Recursos de COVID - 19 Immigration Services Other
LAA External Referrals

Mental Health / Salud mental Attorneys / Abogados Consular assistance / Asistencia consular Resume assistance / Ayuda con Hoja de Vida Other
Comments / Comentarios
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Welcome to the Latino Youth Leadership Academy Mentoring Program

Student Information

Student Mentee Information

Parent Information

Select LAA Services you would like to receive