FRFL - MENTEE APPLICATION

MENTEE APPLICATION
INSTRUCTIONS:

Please complete form in its entirety. Form to be completed by prospective mentee or caregiver/custodian. Return to Family Roots staff at: info@familyrootsforlife.org.
Youth's First Name:
Youth's first name
Youth's Last Name:
Youth's last name
Email:
example@example.com
Residence Address (Apartment #):
Residence Address
Mobile Number:
Mobile NumberFormat: (000) 000-0000.
Date of Birth:
Date of Birth
Gender:
Optional:
Race/Ethnicity:
Optional
Age:
Age
Language Preference:
Language Preference:
Name of School:
Name of School
Grade/Year in School:
Grade Level
Residential Facility/Family Home:
Residential Facility/Family Home
Legal Guardian Name:
Legal Guardian Name
Legal Guardian Address:
Legal Guardian Address
Legal Guardian Phone Number:
Leagal Guardian Phone NumberFormat: (000) 000-0000.
Legal Guardian E-mail:
Legal Guardian E-mail
Youth's Legal Status:
Youth's Legal Status
Permanency Plan:
Permanency Plan
DFPS/CPS Specialist Name:
DFPS/CPS Specialist
DFPS/CPS Specialist Phone #:
DFPS/CPS Phone NumberFormat: (000) 000-0000.
DFPS/CPS Specialist Email:
DFPS/CPS Specialist Email
Juvenile Probation Officer Name:
Juvenile Probation Officer Name
Juvenile Probation Officer Phone #:
Juvenile Probation Officer Phone #
Juvenile Probation Officer Email:
Juvenile Probation Officer Email
Circle all words that best describe your personality:
Describe yourself in three words:
Describe yourself in 3 words
Please share any special needs/conditions that we should be made aware of:
Any special needs/conditions
Your hobbies and interests:
Your preferred method of communication with your mentor:
Career interest(s):

Other
The role(s) you would like your mentor to serve as:
Areas where you hope your mentor would make an impact:
Have you ever had a mentor?
Your preferred mentor:
Signature certification
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearToday's Date
Any questions may be submitted to the below e-mail address:

info@familyrootsforlife.org
Website: www.familyrootsforlife.org

Inquiries: info@familyrootsforlife.org
Please verify that you are human
Should be Empty: