Renaissance Mentee Youth Application

Renaissance Mentoring: Mentee Application

Please answer these questions as completely as possible. This information will help us to match you with the right mentor. (Please print)
Today's Date

MonthDayYear
Date
Child's Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Male or Female
School Name
Race/Ethnicity
Child's T-shirt Size
Child's Photo

Cancelof
Special Education/Disability? Y/N
Juvenile Court JudgeFamily CourtLaw Enforcement OfficerSchool OfficerSchoolOther
Have you previously been a PAL member?
Parent/Legal Guardian's Name
My favorite kind of music is
My favorite television show is
My favorite sport is
My favorite book is
My favorite subject in school is
My least favorite subject in school is
What are your special interests and hobbies (sports, arts & crafts, computers, music, reading, cooking, games, painting, etc.)?
What clubs or groups do you belong to?
What do you like to do most with your free time?
Why do you want to be a part of the PAL Mentoring program?
Are you interested in the Rescue Retreat?
If accepted into the PAL Mentoring program, - agree to participate for a full year. I agree to meet with my mentor at the PAL center during weekly PAL Mentoring sessions and will tell the PAL center staff any time I can't make it to a session.
Signature of Youth
Parent's Name

First NameLast Name
Parent's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature of Parent or Legal Guardian
Should be Empty: