Mentee Application
Youth's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
School and Grade
Ethnicity
Please Select
White
African American
Hispanic
Asian
Native American
Other
Please select all that apply
Food Stamps
Free/Reduced School Lunch
Foster Care
Mental Health (Anxiety, Depression, ADHD, etc)
Medicaid
Parent/Guardian Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
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Application Questions
Please answer all of the following questions as completely as possible.
Why do you/your child want to participate in a mentoring program?
Is your child available to meet with a mentor 2-4 times per month and have contact at least once a week for a minimum of a school year? Please explain any particular scheduling issues.
Is your child willing to attend an initial mentee interview/orientation session prior to being matched?
Describe your child’s school performance including grades, homework, attendance, behaviors, etc.
Please describe your child’s friendships.
Has your child experienced any traumatic events (i.e., death in the family, abuse, divorce)?
Can you provide any additional background information that may be helpful to MENT2B in matching your son/daughter with an appropriate mentor?
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Emergency Contact Information
Emergency Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Mentee Interest Survey
(To Be Completed by Youth) Please complete all of the following survey questions. This survey will help MENT2B Program know more about you and your interests and help us find a good match for you.
What are the most convenient times for you to meet with your mentor? Please check all that apply.
Weekdays
Afterschool
Evenings
Weekends
Do you speak any languages other than English? If so, which languages?
What are some favorite things you like to do with other people?
What are your favorite subjects in school?
What is one goal you have set for the future?
What person do you most admire and why?
Describe your perfect Saturday:
Please check all activities you are interested in:
Animals/Pets
Camping
Gardening
Movies
Science
Swimming
Art
Card Games
Golf
Music
Shopping
Technology
Biking
Computers
Health & Fitness
Theater
Cooking
Hiking
Parks
Writing
Fishing
Library
Sports
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