TUC New Mentee Application

Team Up Connections
9424 Harrisburg Road
Charlotte NC 28215
(704) 905-5849
TeamUpConnections.org
Robin@TeamUpConnections.org

https://form.jotform.com/230473711378154
Team Up Connections New Mentee Application

To Be Completed by Parent/Guardian
Today's Date*

MonthDayYear
Date
Youth Name*

First NameMiddle NameLast Name
Parent/Legal Guardian Name*

First NameLast Name
Relationship to Youth*

MotherFatherGuardianAgency
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Phone Number

Area CodePhone Number
Parent/Legal Guardian Email*
example@example.com
Parent/Legal Guardian Email
example@example.com
Youth's Age*
Youth's Birth Date*
DD-MM-YEAR
Gender
Ethnicity

Black/African AmericanWhiteHispanicAsianOther
Youth Email
example@example.com
Name of Court Counselor or Social Worker (if applicable)

First NameLast Name
Name of Youth's School*
Grade*
Emergency Contact Name*
Emergency Contact Phone*

Area CodePhone Number
Please list all members of mentee's household:

Name
Gender
Age
Relationship to Mentee
Name
Gender
Age
Relationship to Mentee
Name
Gender
Age
Relationship to Mentee
Name
Gender
Age
Relationship to Mentee
Name
Gender
Age
Relationship to Mentee
Name
Gender
Age
Relationship to Mentee
Name
Gender
Age
Relationship to Mentee
Name
Gender
Age
Relationship to Mentee
Application Questions

Tell us more about you
Why do you/your child want to participate in Team Up Connections Mentoring program?*
Briefly describe your expectations from Team Up Connections Mentoring program?*
Will your child be available to meet with a mentor eight hours per month and have face to face contact once a week for a minimum of ten months? Please explain any particular scheduling issues.
Will your child be willing to attend the initial mentee training session and two additional training sessions throughout the time enrolled in TUC?
Please describe your child's school performance, including grades, homework, attendance, behavior, etc.
Does your child have friends? Please describe his/her friendships.
Is your child currently having problems either at home or school? Please describe some of those problems.
Has your child experienced any traumatic events (i.e death in the family, abuse, divorce)? If yes, please provide details. *
Can you provide any additional background information that may be helpful to Team Up Connections in matching your son/daughter with an appropriate mentor?
Medical History
Name of Primary Care Physician
Primary Care Physician Phone #

Area CodePhone Number
Medical Insurance Provider
Policy #
Insurance Company Phone #
Phone Number
Does your son/daughter have any physical problems or limitations?

YesNo
If Yes, please explain.
Is your son/daughter currently receiving treatment for medical issues?

YesNo
Is he/she currently receiving medical treatment or on medication, please specify?
Does your son/daughter have any allergies or adverse reactions to medications? If yes, please describe them below.
Does your son/daughter have any emotional or mental health concerns right now? If yes, please explain.
Is your son/daughter currently seeing a counselor or therapist?

YesNo
If yes, please list the therapist or counselors name.
Please list the counselor or therapist phone #

Area CodePhone Number
Please read this section carefully before signing.
Team Up Connections 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 son/daughter to participate in the Team Up Connections Mentoring Program.

After receiving this completed application from you, we will evaluate the information and send you a letter informing you if your child has been accepted in the mentoring program. Much of the information you supply in this application process will be used to match your child with an appropiate 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 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 after each of the following statements.
I give my informed consent and permission for my child to participate in Team Up Connections Mentoring Program and its related activities.
Initials*
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 this mentoring relationship.
Initials*
I hearby acknowledge that my child will be transported by his/her mentor and/or Team Up Connections staff or representatives while participating in Team Up Connections Mentoring Program, and that such transportation is voluntary and at his/her own risk.
Initials*
I release Team Up Connections 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 Team Up Connections mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.
Initials*
(Optional) I agree to allow Team Up Connections to use any photo/video image of my child taken while participating in the mentoring program. These images may be used online or in print in promotions or other related marketing materials.
Initials
I understand I must complete all items of this application and any incomplete information will result in the delay of my application being processed.

By signing below, I attest to the truthfulness of all information listed on this application and agree to all the terms and conditions.
Parent/Legal Guardian Signature*

Clear
Today's Date*

MonthDayYear
Date
Parent/Legal Guardian Contract
Name of Parent/Legal Guardian*

First NameMiddle NameLast NameSuffix
By allowing my son/daughter to participate in Team Up Connections Mentoring Program, I agree to the following:
- Allow my child to participate in the Team Up Connections Mentoring Program and to be matched with a Team Up Connections mentor.
- Follow and encourage my child to follow all rules and guidelines as outlined by the Program Manager, mentee training, program policies, and this contract.
- Support my child in this match by allowing him/her to meet with his/her mentor at least 8 hours per month and have weekly contact with him/her for a minimum of 10 months.
- Support my child being on time for scheduled meetings or have him/her call the mentor at least 24 hours beforehand if unable to make a meeting.
- Regularly and openly communicate with the Program Manager as requested.
- Inform the Program Manager if I observe any difficulties or have areas of concern that may arise in the match relationship.
- Participate in a closure process when tht time comes.
- Notify the Program Manager if I have any changes in address or phone number.
- Provide the Program Manager and the mentor with any updated health insurance information for my child.
(Please Initial Below) I understand that upon match closure, future contact between my child and his/her mentor is beyond the scope of Team Up Connections mentoring program, and can happen only by the mutual consensus of the mentor, this mentee, and myself.
Initials*
I agree to follow all the above stipulations of this program as well as any other conditions as instructed by the Program Manager at this time or in the future.
Parent/Legal Guardian Signature*

Clear
Today's Date*

MonthDayYear
Date
Contact and Information Release

To Be Completed by the Parent/Legal Guardian
Youth's Name*

First NameMiddle NameLast Name
Name of Youth's School*
I hereby grant permission for Team Up Connections Mentoring Program to make contact with my child and conduct a personal interview for the purposes of applying to be a mentee. Team Up Connections 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 Team Up Connections 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/Legal Guardian's Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Legal Guardian Signature*

Clear
Today's Date*

MonthDayYear
Date
Personal References

Please list the names, addresses, and phone numbers of three people you would like to use as character references (only people you have known for at least a year). Please include at least one relative. Any information Team Up Connections Mentoring Program gathers from these references will be held as confidential and not released to you, the applicant.
Relative's Name*

First NameLast Name
Phone #*

Area CodePhone Number
Relationship to Mentee*
Grandparent, Sibling, Cousin, Etc.
Length of Time Known*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Reference's Name

First NameLast Name
Phone #

Area CodePhone Number
Relationship to Mentee
Former Employer, Teacher, Friend, Etc.
Length of Time Known
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Reference's Name

First NameLast Name
Phone #

Area CodePhone Number
Relationship to Mentee
Former Employer, Teacher, Friend, Etc.
Length of Time Known
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Mentee Interest Survey

To Be Completed by Youth
Please complete all of the following. This survey will help Team Up Connections Mentoring Program know more about you and your interests to 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:

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Do you speak any language(s) other than English? If so, which language(s)?
What are some favorite things you like to do with other people?
What are your favorite subjects in school?
If you could learn about a job/career, what would it be?
What are your favorite subjects to read about or research online?
What is one goal you have set for yourself for your future?
If you could learn or do something new, what would it be?
What person do you most admire and why?
Would you describe yourself as an introvert or an extrovert?
Describe your ideal Saturday.
Please select any/all the activities you are interested in:

BikingHikingGolfFishingCampingBoatingSwimmingAnimals/PetsScienceListening to MusicPlaying a Musical InstrumentSingingRappingGardeningPaintingPhotographyGraphic DesignCookingSportsBoxingBasketballFootballSoftballSoccerParksBoard GamesLibraryYogaMoviesMechanic/CarsMilitary/JROTCInternetSocial MediaVideo GamesStyle/FashionHair/MakeupOther
Is there anything else you have a special interest in or anything else you would like us to know about you?
Mentee Contract
Youth's Name*

First NameMiddle NameLast Name
By choosing to participate in the Team Up Connections Mentoring Program, I agree to:
- Follow all rules and guidelines as outlined by the program coordinator, mentee training, program policies, and this contract.
- Have a positive attitude and be respectful of my mentor.
- Make a minimum of a 10 month commitment to being matched with my mentor.
- Meet at least 8 hours per month with my mentor.
- Make at least weekly contact with my mentor.
- Obtain parent/guardian permission for all meeting times at least 3 days in advance, if possible.
- Be on time for scheduled meetings or call my mentor at least 24 hours beforehand if I am unable to make a meeting.
- Discuss monthly meeting times and activities with the program coordinator, and regularly and openly communicate with the program coordinator as requested.
- Inform the program coordinator of any difficulties of areas of concern that may arise in the relationship.
- Participate in a closure process when that time comes.
- Notify the program coordinator if I have any changes in address or phone number.
- Attend mentee training sessions twice per year.
(Please Initial Below) I understand that upon match closure, future contact with my mentor is beyond the scope of Team Up Connections Mentoring Program and can happen only by the mutual consensus of the mentor, the mentee, and my parent/guardian.
Initials*
Today's Date*

MonthDayYear
Date
Youth Signature*

Clear
Parent/Legal Guardian Signature*

Clear
Should be Empty:

Team Up Connections New Mentee Application

Application Questions

Medical History

Please read this section carefully before signing.

Please initial after each of the following statements.

Parent/Legal Guardian Contract

Contact and Information Release

Personal References

Mentee Interest Survey

Mentee Contract