H.U.T.S. Mentee Application

H.U.T.S. Mentee Application

Complete this form and click Submit.
General Information
Location
Group
How did you hear about The Village Indiana?
Parent/Guardian Information
Parent/Guardian Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Would you like to receive text messages from The Village Indiana?
Best time of day to call to set up an interview for you and the prospective youth
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Why does the child need a mentoring program?
Please describe any time constraints or barriers to participating in the mentoring program at least 75% of the time.
Do you believe in God or in the concept of a higher power? If so, describe the most useful and empowering aspects of your relationship with God. If not, what reference point do you use?
Family's yearly income
Student Information
Name
Preferred Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
School
Grade Level
Ethnicity
Preferred Language

Other
Shirt Size
Juvenile Justice System involvement in the last 12 months
Allergies, Special Needs or Other Information
Emergency Contact #1
Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Relationship to Student
Emergency Contact #2
Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Relationship to Student
Waivers
Photo Permission Waiver: I allow the mentoring program to use any photographic image of the mentee in promotions or related marketing materials, including social media.
As a parent/guardian, I give my permission for my child to participate in your organizations' programs. PLEASE TYPE YOUR NAME BELOW signifying an e-signature.
Should be Empty:

H.U.T.S. Mentee Application

General Information

Parent/Guardian Information

Student Information

Emergency Contact #1

Emergency Contact #2

Waivers