Personal InformationYouth's Name: First Name* Last Name* Date: Date* Parent/Guardian Name: First Name* Last Name* Relationship to Youth: Specify relationship* Street Address: Street Address* Address Line 2* City* State* Zip* Home Phone: Area Code* Phone Number* Work Phone: Area Code* Phone Number* Youth Social Sec. #: Number* Date of Birth: Date* Age: Number* Gender: * Ethnicity: Please SelectWhiteHispanicAfrican AmericanAsianOther* If other, specify: Type a label* Name of School: Type a label* Grade: Type a label* Emergency Contact Name: First Name* Last Name* Emergency Contact Phone #: Area Code* Phone Number*
Please answer all of the following questions as completely as possible.
On a scale of 1-10 (10 being highest) rate the youth's level of:* Academic performance* Family Support* Attitude about school/education* Social skills* Communication skills* Peer relations* Self-esteemMedical HistoryName of the Primary Care Physician: Type a label* Phone #: Area Code* Phone Number* Medical Insurance Provider: Type a label* Policy #: * Phone #: Area Code* Phone Number*
Please read this carefully before signingHeartlink Mentoring Program appreciates you and your child's interest in becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their child to participate in the Heartlink 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 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 first upon anonymous information provided about each other.Please initial each of the follow:Type a label* I give my informed consent and permission for my child to participate in the Heartlink Mentoring Program and its related activities.Type a label* I agree to have my child follow all mentoring program guidelines and understand that any violation on my child's part may result in suspension and/or termination of the mentoring relationship.Type a label* I hereby acknowledge that my child will be transported by his/her mentor and/or Heartlink staff or representatives while participating in the Heartlink Mentoring Program, and that such transportation is voluntary and at his/her own risk.Type a label* I release Heartlink Mentoring Program of all liability of injury, death, or other 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 Heartlink mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.Type a label* (Optional) I agree to allow Heartlink to use any photographic image of my child, taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.Parent/Guardian Signature:Signature* Date: Date*
I hereby grant permission for Heartlink Mentoring Program to make contact with my child and conduct a personal interview for the purposes of applying to be a mentee. Heartlink may also make contact with my child on school premises for the purposes of screening and interviewing as well as ongoing support of his/her participation in the mentoring program.
I authorize Heartlink to obtain any needed information regarding my child from his/her school's staff, including academic and behavioral records and conversations with teachers, counselors, and other administrative staff.
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: Signature* Date: Date* Parent/Guardian Name: First Name* Last Name* Address: Street Address* Address Line 2* City* State* Zip*
Please complete all the following. This survey will help Heartlink Mentoring Program know more about you and your interest and help us find a good match for you.