Mentee Application

Mentee Application

William G and Kathie Beattie Mentoring Program
Student's Name

First NameLast Name
Student's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Phone Number
Format: (000) 000-0000.
Cell Phone Number
Format: (000) 000-0000.
Email Address
Student's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Student is Attending
E.G. Danbury HS or Middle School, Danbury West, Tech, etc.
Current Grade of Student:
Favorite Subject
Least Favorite Subject
What clubs or activities is the student involved in?
Does student volunteer though school or in the community?
Student's home church (optional):
Name & City
Years attending:
Student and Parent/Guardian Authorization

By signing below, you agree to participate in the follow-up process with our Ministry Director. This includes an interview with the applicant and his or her parent(s)/guardian(s), as appropriate.
Please be advised that receipt of your application does not guarantee acceptance into the Jericho Partnership Willam G and Kathie Beattie Mentoring Program. Our decision to accept an applicatnt is based on several factors, including our assessment of suitability during the interview session.
Student Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Student and Parent/Guardian Authorization