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
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
County / Condado
*
Please Select
Fulton
Dekalb
Gwinnett
Cobb
Henry
Cherokee
Clayton
Fayette
Coweta
Douglas
Barlow
Forsyth
Rockdale
Carroll
Hall
Paulding
Spalding
Other GA County
I do not know / Desconozco
Student's birthday
*
-
Month
-
Day
Year
Date Picker Icon
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
*
Please Select
6th
7th
8th
9th
10th
11th
12th
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
Please Select
Healthcare (Doctor, Nurse)
Creative (Music, Performing Arts, Graphic Design)
Design (Engineer, Architect)
Education (Teacher, Professor)
Law
Business/Finance
Trades (Carpentry/Construction, Plumbing, Welding, Automotive)
Own my own business
Scientist (Biologist, Chemist, Physicist, Public Health)
Service Industry (Food, Hospitality)
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
*
Please Select
Own vehicle/ Automóvil propio
Use public transportation / Utilizo transporte publico
Walk / Camino
Family or Friends / Familia y amigos
Use Lyft or Uber / Utilizo Lyft o Uber
No transportation / No tengo 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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