Mentorship Application

Mentorship Application

Thanks for your interest in our mentorship program! Our goal is to provide personalized and impactful support for your child. The information you’ve included in the application will help us tailor the experience to meet their individual needs
Student Information
Student's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Preferred Name
Gender*

MaleFemale
Current School*
Grade Level
Legal Guardian(s)
Parent/Guardian 1
Parent/Guardian Name*

First NameLast Name
Relationship*
Primary Phone Number*
Secondary Phone Number
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2
Parent/Guardian Name

First NameLast Name
Relationship
Primary Phone Number
Secondary Phone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Relationships
Who does your child live with?*

Biological Parent(s)Adoptive Parent(s)Foster Parent(s)Grandparent(s)Other
Are both parents involved in your child's life?*

YesNo
Which parent/guardian is involved?*
Describe relationship with parents:*
Does your child have siblings?*

YesNo
Describe relationship with siblings:*
Student Background
What is your child's favorite snack and drink?*
What is his/her favorite fast food restaurant?*
Is he/she involved in any teams or clubs?*

YesNo
Please list each team and/or club:*
What are your child's interests?*
What are his/her hobbies?*
What are his/her strengths?*
What are his/her weaknesses?*
What are his/her challenges?*
Describe his/her academic performance?*
What do you want your child to gain from this program?*
How social is your child?*
How well does he/she follow directions?*
How trustworthy is he/she?*
Describe your child's social and behavioral history:*
Does your child have issues dealing with anger?*

YesNo
Please provide a description:*
Does he/she have a history of running away?*

YesNo
Please provide a description:*
Does he/she have a history of self harm?*

YesNo
Please provide a description:*
Has he/she ever attempted suicide?*

YesNo
Please provide a description:*
Does he/she have a mental health diagnosis?*

YesNo
Please provide a description:*
Has he/she been prescribed psychiatric medication?*

YesNo
Please describe the medication:*
Does he/she currently receive counseling services?*

YesNo
Please provide a description:*
Does he/she have a criminal history?*

YesNo
Please provide a description:*
Is he/she on probation?*

YesNo
Please provide a description:*
Is he/she known to steal?*

YesNo
Please provide a description:*
Does he/she smoke, vape, drink or use other illegal substances?*

YesNo
Please provide a description:*
Is your child gang affiliated?*

YesNo
Please provide a description:*
By my signature, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge*

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