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. 

Medical History 

Please read this carefully before signing:

We appreciate you and your child's interest in her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their 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 if participating in one-on-one mentoring. This information will be taken into consideration when placing your child in group mentoring with other children. 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 about each other,

Please INITIAL each of the following-

I give my informed consent and permission for my child to participate in the MAQ 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.

Ihereby acknowledge that my child may be transported by her mentor while participating in the mentorship program, and that such transportation is voluntary and at her own risk.

I release the MAQ Mentoring Program of all liability of injury, death, or damages to me, my child, family, estate, heirs, or assigns that may result from 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

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

Photo Release Youth Mentee Guidelines/Instructions Form

Full payment or a signed payment plan or Financial Assistance application 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.

Contact and Information Release (To Be Completed by the Parent/Guardian)

I hereby grant permission for the MAQ 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.

MAQ Mentoring Program Marquita Clark, Coordinator marquitaclark@mamentoring.org

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 your mentor.

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

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 a 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.

13. Show up, meaning be present in all sessions. Turn cell phones on silent.

14. Bring your MAQ Mentoring Journal to all sessions.