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
QuietSeriousNervousAdventurousShyApproachableCompassionateMoodyWithdrawnPassionateFunnyExtrovertedFriendlyIntuitiveIntrovertedCreativeDiscreetTalkativeTranquilEnergeticLivelyHumbleSpiritualPeacefulReservedConfidentEasy-goingSpontaneousVibrantInquisitiveEmotionalMethodicalReflective
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
Visual ArtsVolunteeringEletronic GamesSportsFilmReadingMusicInstrumentsTravelLiterary WorksPoliticsTheater
Your preferred method of communication with your mentor:
Arts and EntertainmentHealthcare in MedicineAdministrationEducationInformation TechnologyEngineeringLegalPublishingMarketingPoliticsNonprofitBusinessFinancial ServicesScience and TechnologyOther
ListenerMotivatorLife CoachTeacher/TutorCareer DevelopmentOther
Knowledge and practice of professional etiquetteFocus and practice in prospective careerCommunication skills improvementIndependent livingCareer developmentLeadership developmentProfessional network expansionCollege preparationOther
YesNo
Your preferred mentor:
Signature certification*

Clear
Today's Date*

MonthDayYear
Today'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: