Mentee Application

Mentee Application
Child's Information
Child’s Gender

Thank you for your interest in Mentor Connect!

Mentor Connect pairs students in 3rd–8th grade with caring adult mentors who encourage, support, and invest in them throughout the school year. After you submit this form, a representative from Mentor Connect will review your application and contact you with next steps in matching your child with a mentor!

To participate, your child must attend one of our partner schools:

Bay Area	Elementary Schools Cline, Westwood-Bales, Windsong
Greater Tyler	Elementary Schools Clarkston, Dixie, Griffin, Orr, Owens, Peete, Rice, Wise Intermediate/Middle Schools Kissam, EJ Moss, Lindale Jr. High, Hubbard, Three Lakes
Greater Longview	Intermediate/Middle Schools Foster
Greater Waco	Elementary Schools Parkdale Intermediate/Middle Schools Robinson Intermediate, Tennyson

Please plan for 5–8 minutes to complete this application.

Please select your Region
Program Interest
Child's Name

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

MonthDayYear
Date
Child’s Grade Level
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
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.Format: 0000000000.
Parent/Guardian Mobile Telephone Number
Please enter a valid phone number.Format: 0000000000.
Parent/Guardian Work Telephone Number
Please enter a valid phone number.Format: 0000000000.
Parent/Guardian Preferred Communication Method
Parent/Guardian Preferred Time of Day for Communication
Parent/Guardian Preferred Language
If you are currently employed, then please list the name of your employer
General Household Information
Family Structure
Are there any custodial situations that we should be aware of?
If yes, please specify
Does your child receive free or reduced lunch?
Does your child have any medical conditions or allergies we need to be aware of?
If yes, please describe the condition or allergy below.
Does this condition or allergy require any emergency medication?
Please describe the emergency medication and usage below.
Emergency Contacts
Emergency Contact Name

First NameLast Name
Emergency Contact Preferred Telephone
Please enter a valid phone number.Format: 0000000000.
Emergency Contact Preferred Telephone Type
Emergency Contact Email Address
example@example.com
Emergency Contact Relationship to Child
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
Should be Empty:

Mentee Application

Child's Information

Parent/Guardian Contact Information

General Household Information

Emergency Contacts