IMPOWER MOVEMENT, INC.
Mentee Application & Enrollment Form
Parent/Guardian completes this form • Impowermovement@impmvt.org • 904-658-0247
1. YOUTH & PARENT/GUARDIAN INFORMATION
Youth Full Name
*
First Name
Last Name
Youth Preferred Name (if different)
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Grade
*
School
*
Parent/Guardian Name
*
First Name
Last Name
Relationship
*
Best Phone
*
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City/State/ZIP
*
Best way to contact you:
*
Call
Text
Email
Preferred contact time:
*
Morning
Afternoon
Evening
SMS Consent
*
I agree to receive text messages from Impower Movement regarding program updates, reminders, events, schedule changes, and other information related to my participation.
2. PROGRAM FIT & GOALS
Why would you like your child to participate in Impower Movement?
What are 1-2 goals you would like the mentoring program to support?
Youth strengths/interests (check all that apply):
*
Sports
Arts/Music
Gaming/Technology
Academics
Leadership
Career/College
Community Service
Other
Areas where your child may benefit from support:
*
Confidence/Self-esteem
Social skills
School/Academics
Life skills
Leadership
Career/College planning
Stress/Emotional support
Other
Anything important we should know to help us make a supportive mentor match?
3. AVAILABILITY & SCHOOL SNAPSHOT
Can your child commit to approximately 4 hours of mentoring per month for at least 6 months?
*
Yes
No
Unsure
If no/unsure, please note scheduling limitations:
School Attendance/Academic Concerns (brief)
Behavior or Peer Concerns (brief)
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4. HEALTH, SAFETY & SUPPORT INFORMATION
Please provide only information that may affect your child's safety, participation, or mentor support.
Allergies or Dietary/Environmental Needs
Medical/Physical Limitations
Emotional/Behavioral Considerations
Current Counselor/Therapist (if applicable)
Would you like help connecting your child to counseling or other community support?
*
Yes
No
Emergency Contact Name
*
First Name
Last Name
Relationship
*
Phone
*
Format: (000) 000-0000.
5. PARENT/GUARDIAN CONSENT & ACKNOWLEDGMENT
*
I consent to my child's participation in Impower Movement mentoring and related educational, recreational, and enrichment activities.
I agree to support my child in following program rules and understand that serious or repeated violations may result in suspension or removal from the program.
I understand that relevant information may be used to support mentor matching and program safety. Identifying information will be handled confidentially and shared only as appropriate for program purposes.
I understand that participation includes activities and transportation arrangements communicated by the program, and I agree to the program's safety and liability policies.
OPTIONAL - I give permission for Impower Movement to use photos/video of my child for promotional, educational, or marketing purposes.
Parent/Guardian Full Name
*
First Name
Last Name
Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Thank you for helping us create a meaningful and supportive mentoring experience for your child!
OFFICIAL USE
Staff Review Date
Decision / Notes
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