Mentee Application

Mentee Application
Thank you for your interest in finding a Mentor for your child through Mentor Connect!

Mentor Connect matches children in 3rd-10th grades from single-parent or extended family households.

Please set aside 5-8 minutes to complete this application. Once your application has been submitted, a Mentor Coordinator will review it and contact you with your next steps in finding a Mentor for your child.
Region*
Program Interest
Child's Information
Child's Name*

First NameLast Name
Child’s Gender*
Child’s Ethnicity*
Child’s Date of Birth*

MonthDayYear
Date
Child’s Grade Level*
Child's School District*
Child's School*
Child's Preferred Language*
Is your child currently enrolled in Mentoring Alliance After School?*
Has your child attended Mentoring Alliance Summer Camps within the last year?*
Parent/Guardian Contact Information
Parent/Guardian Full Name*

First NameLast Name
Relationship to Child*
Household Name
Parent/Guardian Gender*
Parent/Guardian Ethnicity*
Parent/Guardian Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Country
Parent/Guardian Email Address*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian Mobile Telephone Number
Please enter a valid phone number.
Parent/Guardian Work Telephone Number
Please enter a valid phone number.
Parent/Guardian Preferred Communication Method*

Cell PhoneHome PhoneTextSocial MediaEmailOther
Parent/Guardian Preferred Time of Day for Communication*
Parent/Guardian Preferred Language*
General Household Information
Family Structure*
Are there any custodial situations that we should be aware of?
If yes, please specify
Family Household Income (Annually)
Please enter the number from your most recent tax return (Line 11 on Form 1040)
Does your child receive free or reduced lunch?
Medical/Insurance Company*
Medical/Insurance Policy / Group Number
If you are currently employed, then please list the name of your employer
Emergency Contacts
Emergency Contact Name*

First NameLast Name
Emergency Contact Preferred Telephone *
Please enter a valid phone number.
Emergency Contact Preferred Telephone Type *
Emergency Contact Email Address
example@example.com
Emergency Contact Relationship to Child*
Secondary Emergency Contact Name*

First NameLast Name
Secondary Emergency Contact Preferred Telephone *
Please enter a valid phone number.
Secondary Emergency Contact Preferred Telephone Type *
Secondary Emergency Contact Email Address
example@example.com
Secondary Emergency Contact Relationship to Child*
Tell us some things that your child enjoys doing!

Check all boxes that apply
1.

Arts/Crafts
2.

Board Games
3.

Community Service/Volunteerism
4.

Computer/video games
5.

Cooking/Food
6.

Cultural events
7.

Dance
8.

Drama
9.

Fashion
10.

Movies
11.

Music
12.

Outdoor Activities
13.

Pets
14.

Reading
15.

Shopping
16.

Sports
17.

Sports: Playing Sports
18.

Travel
19.

TV
20.

Writing
Other Interest(s)
Arts/Crafts

Arts/Crafts
Board Games

Board Games
Community Service/Volunteerism

Community Service/Volunteerism
Computer/video games

Computer/video games
Cooking/Food

Cooking/Food
Cultural events

Cultural events
Dance

Dance
Drama

Drama
Fashion

Fashion
Movies

Movies
Music

Music
Outdoor Activities

Outdoor Activities
Pets

Pets
Reading

Reading
Shopping

Shopping
Sports

Sports
Sports: Playing Sports

Sports: Playing Sports
Travel

Travel
TV

TV
Writing

Writing
How did you hear about Mentor Connect?*
If you said other, please specify:
I hereby give consent for the release of any and all school records pertaining to my child, which may be pertinent to the improvement of academic skills, to a representative of Mentor Connect.*
In order to maintain quality services for my child, Mentor Connect staff and/or the child's mentor may need to have contact with your child's teacher and/or school staff. I hereby consent to and approve of these interactions. *
I give permission for Mentoring Alliance to take photos and/or videos of my child. I understand that said media may be used alongside my child’s first name for advertising, marketing, or other communication purposes. I reserve no right to any royalties or fees from said media.*
Parent/Guardian Signature

Clear
Should be Empty:

Mentee Application

Child's Information

Parent/Guardian Contact Information

General Household Information

Emergency Contacts

Tell us some things that your child enjoys doing!