MENTEE APPLICATION – Meet 'Em at the Stoop

1

Full Name

First Name

Last Name

2

Preferred Name/Nickname

3

Age

4

Birth Date

Date

5

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

6

Parent/Guardian Name (if under 18)

7

Parent/Guardian Phone Number (Phone)

8

Current School or Program

9

Grade Level or Highest Grade Completed

10

Are you currently working?

11

Preferred Days/Times for Mentorship

Weekday Afternoons

Weekday Evenings

Saturdays

Sundays

12

What made you interested in joining Meet 'Em at the Stoop?

13

What goals do you have for yourself over the next year?

14

What do you hope to gain from your mentor?

15

What are 3 things you’re proud of or passionate about?

16

What challenges are you currently facing that you’d like support with?

17

What are your hobbies or interests?

18

How do you like to communicate?

Text

App

Email

Phone Call

19

Is there anything you don’t feel comfortable discussing with a mentor?

20

Do you have any mental health or emotional wellness support currently in place?

Yes

No

21

Do you need any accommodations or assistance?

22

Type a question

Yes

No

23

Digital Signature

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24

Parent/Guardian Signature (Only show if applicant is under 18)

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