Youth Mentee Application 🌹
Please complete this form to apply for mentorship and support.
Youth Information
Are you between the ages of 8–18 years old?
*
Yes
No
Age
*
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Female
Male
Non-binary
Prefer to self-describe
Prefer not to say
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Parent/Guardian Information
Parent/Guardian Full Name
First Name
Middle Name
Last Name
Relationship to Youth
Please Select
Parent
Legal Guardian
Grandparent
Aunt/Uncle
Sibling
Foster Parent
Other
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Referral Partner
Referral Partner Name
Referral Partner Title
Referral Partner Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are they on probation?
Yes
No
Probation Officer Name
Are you the parent/legal guardian completing this form?
*
Yes
No
School Information
Current school name
*
Current grade level
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Teacher or counselor name
School Counselor Contact Information
Youth Interests & Personality
Hobbies or activities you enjoy
*
Sports
Music
Art
Dance
Gaming
Reading
Fitness
Entrepreneurship
Fashion
Technology
Community Service
Other
What type of support would help you most right now?
*
Confidence Building
Emotional Support
School Motivation
Life Skills
Anger Management
Positive Friendships
Career Guidance
Mental Health Support
Conflict Resolution
Leadership Skills
Other
Additional Background
Has the youth ever experienced any of the following?
Bullying
Loss/Grief
Anxiety/Stress
Community Violence
Family Challenges
Behavioral Challenges
School Suspension/Discipline Issues
Juvenile Justice Involvement
None
Prefer Not to Answer
Is there anything mentors should know about the youth to better support them?
Program Participation
Will you participate in mentorship meetings, activities, and community events?
*
Yes
No
Do you agree to follow respectful behavior and participation expectations in the program?
*
Yes
No
Final Reflection
What do you wish adults understood more about kids your age?
*
What are your goals or dreams for the future?
*
Is there anything else you would like the program to know about you or your story?
Submit
Youth Full Name
*
First Name
Middle Name
Last Name
Should be Empty: