757 We Care Mentee Application

Together We Can Mentorship Program

We are excited that you are interested in our Youth Mentorship Program! 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 757 We Care Mentoring Program.

Youth's Name*

First NameLast Name

Parent/Guardian Name*

First NameLast Name

Relationship to Youth*

MotherFatherOtherOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Date of Birth*

Date

Gender*

MaleFemale

Ethnicity*

E-mail*

Grade*

Name of School*

Emergency Contact*

First NameLast Name

Emergency Contact's Phone Number*

Area CodePhone Number

Please list all members of your household. (Name, Sex, Age, Relationship)*

Why do you/your child want to participate in a mentoring program?*

0/250

Briefly describe your expectations for the 757 We Care Mentoring Program.*

0/250

Is your child available to meet with a mentor five hours per month and have contact at least once a week for a minimum of one year? Please explain any particular scheduling issues.*

0/250

Is your child willing to attend an initial mentee training session and two training sessions per year after being matched?*

0/250

Describe your child's school performance including grades, homework, attendance, behaviors, etc.*

0/250

Does your child have friends? Please describe his/her friendships.*

0/250

Is your child currently having any problems at home or school?*

0/250

Has your child experienced any traumatic events (i.e., death in the family, abuse, divorce)? If yes, please provide details.*

0/250

Can you provide any additional background information that may be helpful to 757 We Care in matching your son/daughter with an appropriate mentor?*

0/250

Medical History

Name of Primary Care Physician*

Phone Number*

Area CodePhone Number

Medical Insurance Provider*

Policy Number*

Does your son/daughter have any physical problems or limitations?*

Is your son/daughter currently receiving treatment for any medical issues?*

Is he/she currently on any tyle of medication? Is so please specify.*

Does your son/daughter have any known allergies or adverse reactions to medications? If yes, please describe.*

Does your son/daughter have any emotional issues or problems right now?*

Is your son/daughter currently seeing a counselor or therapist?*

Therapist Name

First NameLast Name

Please read each of the following before agreeing to each item.

After receiving this completed application from you, we will evaluate the information and follow up via email. Much of this information you supply in the application packet will be used to match your child with an appropiate mentor. Therefore, the mentoring staff may , at times, need to access and share this informaiont with prospective mentors and other parties when it is the best interest of the match. However, we do not reveal names unitil there is an initial interest from the mentee, parent/guardian, and mentor based first upon anonymous information provided about each other.

I give my informed consent and permission for my child to participate in the 757 We Care Mentoring Program and its related activities.*

AgreeDisagree

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 the mentoring relationship.*

AgreeDisagree

I hereby acknowledge that my child maybe transported by his/her mentor and /or 757 We Care staff or representatives while participating in the 757 We Care Mentoring Program, and that such transportation is voluntary and at his/her own risk.*

AgreeDisagree

I release the 757 We Care 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 757 We Care mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.*

AgreeDisagree

I agree to allow 757 We Care to use any photographic image of my child taken while participating in the mentoring program. These images may be used in promotions or other related marketing material.*

Agree

By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

Signature*