MENTEE (YOUNGIN) APPLICATION FORM

HOPE UNITED COMMUNITY DEVELOPMENT CORPORATION
AFRICAN AMERICAN MALE ALLIANCE MENTORING PROGRAM. "BROTHERS SERVING BROTHERS"
A catalyst of hope in North Minneapolis-connecting people, organizations and resources to transform lives and communities for good
MENTEE (YOUNGIN) APPLICATION FORM

Please complete the following mentee application and have your parent(s) or guardian sign. If you should have any questions, please call Norman Harrington, Program Coordinator (952)240-5788.
Young Man's Information

	Name (First & Last)	Birth date	Birth place	Cell Phone
Mentee
Mentee #2 (if additional students)

Young Man's School Information

	School Attending	Grade
Mentee
Mentee #2 (if additional students)

Young Man's Email *
example@example.com
2nd Young Man's Email (If Applicable)
example@example.com
Briefly Describe What You Aspire To Do With Your Life*
List Extracurricular Activities:*
Parent and/or Guardian's Information

	Name (First & Last)	Cell Phone Number	Work Phone Number	Home Phone Number
Parent
Guardian (If different than the parent)

Parent/Guardian Email*
example@example.com
Emergency Contact (if different than parent)
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Parent/Guardian Agreement
I, the parent/guardian of the minor participant, recognize the possibility of physical injury or loss associated with this outing, and hereby agree to release, discharge, and/or otherwise indemnify Hope United Community Development Corporation and its Board of Directors, staff, volunteers, affiliated organizations, partners, and sponsors, their employees and associated personnel, including the owners of the facilities where the event is being hosted, against any claim by or on behalf of the participant as a result of the participant’s participation in this activity and/or being transported to or from the same, which transportation I hereby authorize. I also understand that Hope United has no liability insurance coverage on my child and that my child is covered by my personal insurance.
Parent/Guardian (Print)*

First NameLast Name
Signature*

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CONSENT FOR MARKETING (Optional)
I understand that Hope United would like to feature photos of its participating mentees (youth) in its marketing and promotional materials. I give Hope United my consent to use photos, video, images and testimonies from me and my children. I understand Hope United does not make any commitment to provide any type of monetary compensation for the use of photos, images and/or testimonies.
Signature

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HOPE UNITED COMMUNITY DEVELOPMENT CORPORATION

AFRICAN AMERICAN MALE ALLIANCE MENTORING PROGRAM. "BROTHERS SERVING BROTHERS"

MENTEE (YOUNGIN) APPLICATION FORM

Young Man's Information

Young Man's School Information

Parent and/or Guardian's Information

Emergency Contact (if different than parent)

Parent/Guardian Agreement

CONSENT FOR MARKETING (Optional)