• 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

  • Date of Birth*
     - -
  • Gender*

  • Legal Guardian(s)

  • Parent/Guardian 1

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Parent/Guardian 2

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Family Relationships

  • Who does your child live with?*
  • Are both parents involved in your child's life?*
  • Does your child have siblings?*

  • Student Background

  • Is he/she involved in any teams or clubs?*
  • Does your child have issues dealing with anger?*
  • Does he/she have a history of running away?*
  • Does he/she have a history of self harm?*
  • Has he/she ever attempted suicide?*
  • Does he/she have a mental health diagnosis?*
  • Has he/she been prescribed psychiatric medication?*
  • Does he/she currently receive counseling services?*
  • Does he/she have a criminal history?*
  • Is he/she on probation?*
  • Is he/she known to steal?*
  • Does he/she smoke, vape, drink or use other illegal substances?*
  • Is your child gang affiliated?*
  • Should be Empty: