Mentee Application Form

Mentee Application Form

Alani's Outreach is a non-profit organization dedicated to empowering and supporting at-risk youth and young adults aged 12-20. The purpose of this program is to educate those involved in leadership, social-emotional intelligence, healthy relationships, self advocacy, and develop their passions.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Mentee's phone number*
Email address
Mentee's Date of Birth*

MonthDayYear
Date
Gender*
What county does the mentee reside in?*
Alani's outreach is only serving Oakland County as of 1/23/25. Please stay tuned for updates on our expansion!
School Name and grade*
Put N/A if not currently enrolled
Parent/Guardian Name (if over 18, please include an emergency contact in this space.)*

First NameLast Name
Phone number *
What is something you would like to learn/experience while involved in the mentoring program?
Ex: interested in cosmetology, sports, wants to learn financing, etc.
Is there anything that we should be aware of that may trigger the mentee?
Ex: suicide, sexual abuse etc.
Does the mentee have any issues or limitations that are staff should be aware of?
Ex: allergies, physical limitations etc.
What days is the Mentee available to meet with their mentor?*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What times is the Mentee available on the days listed?
Mentee Release Statement

I give my consent for Alani's Outreach to match my child with a mentor within the organization. I give consent for myself or my child to partcipate in all Alani's Outreach activities, this includes meeting with outside contracted vendors under the supervision of the mentor, and transportation with the mentor to activities. In consideration of the advantages of partcipation in the mentor program, the undersigned agrees that Alani's Outreaches mentors, its agents, and employess shall be released and exempt from any liability for damages for bodily injuries or property damage that may occur as a result of partcipation.
Photo/Video Release

I give my consent for Alani's outreach, its agencts, and its employees to take photos and videos of myself/my child for the purpose of publication, promotion, illustration, advertising, or trade in any manner and medium. I hearby release Alani's Outreach and its legal representatives for all claims and liability relating to said images and videos.
Virtual Platform Release

I give permission for myself/my child to partcipate in virtual programming via virtual platform such as Microsoft Teams and Zoom.

Meeting links may be sent to the Mentee's email or phone number.
I have read and agree with the following releases: Mentee, photo/video, and virtual platform.

AgreeDisagreeOther- Please contact staff regarding your concerns.
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