& Me Summer PARENT/GUARDIAN Application
*For parents & guardians | Program Duration: June 20 – September 22, 2025 | Mentoring Format: Virtual & Flexible Participation | Thank you for your interest in enrolling your child in & Me mentorship program! Our mentorship program is designed to help young black girls learn and improve confidence, leadership skills, and resilience. Please complete this form so we can understand how to best support your child.
Parent/Guardian Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Child
Parent
Guardian
Other
Child's Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Grade Level
School Name
Next Semester START Date (after summer)
-
Month
-
Day
Year
Date
Next Semester END Date (after summer):
-
Month
-
Day
Year
Date
Program Goals & Expectations
Why do you want your child to participate in this mentorship program?
What are the main areas of growth you would like to see in your child through this mentorship? (check all that apply)
Speaking Up & Being Heard
Making Friends & Social Skills
Building Self-Confidence
Trying New Things
Focusing & Finishing What She Starts
Leadership Skills
Building a Growth Mindset
Understanding Money & Money Management
Other
What challenges does your child currently face that mentoring could help with?
Child's Skills, Talents, & Interests
What are your child's strengths and natural talents (check all that apply):
Art & Creativity (drawing, painting, designing, crafting)
Reading & Writing (storytelling, poetry, or creating books)
Singing, Acting, or Performing (dancing, singing, being on stage)
Curiosity & Problem-Solving (science, technology, discovering how things work)
Caring & Helping Others (kind, enjoys giving advice, helping classmates & family)
Sports & Movement (running, playing outside, gymnastics, team sports)
Big Imagination & Ideas (invents new things, make up stories, new projects)
Business & Leadership (selling things, organizing, being in charge)
Other
What hobbies or activities does your child enjoy the most?
Does your child have any personal projects or goals they are working on?
Yes (Please explain in "other" space)
No, but they are interested in starting something!
Other
Availability & Participation
How much time per week can your child dedicate to mentoring?
1-2 hours per week
3-5 hours per week
Flexible, depending on schedule
Preferred mentoring format:
In-Person (Include how far you are willing to travel for your child to meet with their mentor, in the "other" space
Virtual
Both
Other
How do you prefer to communicate with your mentor? (Check all that apply)
Phone/Video Calls
Text Messages/Telegram
Email
Other
Parent/Guardian Involvement
Would you be open to periodic parent/guardian check-ins to discuss your child’s progress?
Yes
No
Would you like to receive additional resources on confidence-building and personal development for your child?
Yes
No
Do you have any skills, expertise, or resources that could benefit the program (guest speaking, volunteering, event planning)?
Yes (Please explain in the "other" space)
No, but I'd love to support in other ways
Other
Health & Safety Information
Does your child have any medical conditions, allergies or special needs we should be aware of?
Yes (Please explain in the "other" space)
No
Other
Does your child have any emotional or behavioral challenges we should consider to better support them?
Yes (Please explain in the "other" space)
No
Other
Does your child take any medications that might impact their participation in sessions?
Yes (Please explain in the "other" space)
No
Other
Parent/Guardian Consent & Agreement
Do you consent to your child participating in this mentorship program?
Yes
No
Do you give permission for your child to engage in group discussions (when applicable) and mentorship sessions?
Yes
No
Do you consent to your child being photographed or recorded during mentorship activities for program highlights and promotional use?
Yes
No
Do you understand that while mentors are here to provide support and encouragement, they are not licensed counselors, therapists, or medical professionals?
Yes
Media Consent
Do you give permission for photos or video recordings of your child to be taken during program events, sessions, or activities for use in the & Me's promotional materials (such as flyers, social media, website, or highlight videos)?
Yes, I give permission for my image to be used for promotional purposes.
No, I do not give permission for my image to be used
Final Confirmation
By submitting this form, you confirm that all information provided is accurate, you agree to allow your child to participate in the mentorship program and understand the expectations for engagement and support.
Next Steps
Once submitted, we will review your application and match your child with a suitable mentor. You will receive an onboarding guide and details about the mentorship process before the program starts.
Submit
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