2024 - 2025 Mentee Application

Mentee Application

(To be completed by the Parent/Guardian)

Please complete all information and answer all questions. Only complete forms will be processed! All information provided remains confidential and is used for both safety and funding purposes.
PERSONAL INFORMATION
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Instagram Name*
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
This is my:*
E-mail*
If a renewing member, in what year did you first join the Club?
T-Shirt Size:*
SCHOOL INFORMATION
School Name*
City*
Site Location
High School Graduation Year*
Current Grade Level*
Did you progress to the next grade on time?*
Do you speak any languages other than English?*
If yes, please indicate the language and level of reading, written, and oral proficiency.
MEDICAL INFORMATION
Insurance Carrier*
Policy Number*
Allergies*
Medications*
Does your child have any medical conditions and/or disabilities that may affect their involvement in the program?*
If so please specify.
I authorize the G.I.R.L.S. Club staff are that are trained in the basics of first aid and/or CPR to give my child(ren) first aid when appropriate and I give permission to the G.I.R.L.S. Club to seek emergency medical treatment for my child(ren) if I cannot be reached, I will be responsible for any and/or all cost of the medical attention and treatment.
Parent / Guardian Signature:*

Clear
Today's Date*

MonthDayYear
PARENT/GUARDIAN INFORMATION
Full Name*

First NameLast Name
Relationship to Member*
Address (if different from member)

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
This is my:*
E-mail*

EMEGENCY CONTACT INFORMATION
1. Full Name*

First NameLast Name
Relationship to Member*
Phone Number*
Other Contact Number
2. Full Name*

First NameLast Name
Relationship to Member*
Phone Number*
Other Contact Number

APPLICATION QUESTIONS

Please answer all of the following questions as completely as possible.
1. Why do you/your child want to participate in a mentoring program?*
2. Briefly describe your expectations for the G.I.R.L.S. Club Mentoring Program.*
3. Is your child available to participate bi-weekly with the G.I.R.L.S. Club mentoring program? Please explain any scheduling conflicts.*
4. Describe your daughter’s school performance including grades, homework, attendance, behaviors, etc.?*
5. Please describe your daughter’s friendships or social relationships?*
6. Is your daughter currently having any problems either at home or at school? Please explain.*
7. Has your daughter experienced any traumatic events (death in the family, abuse, divorce)? If yes, please provide details.*
8. Can you provide any additional background information that may be helpful to G.I.R.L.S. Club in providing mentorship to your daughter?*

Mentee Interest Survey

(To be completed by child)

Please complete all of the following. This survey will help G.I.R.L.S. Club know more about you and your interests.
1. What are some favorite things you like to do with other people?*
2. What are your favorite subjects in school?*
3. If you could learn about a job/career, what would it be?*
4. What is one goal you have set for the future?*
5. If you could learn something new, what would it be and why?*
6. What person do you admire most and why?*
7. Describe your ideal Saturday?*

Mentee Contract

(To be completed by child)
Mentee's Name*

First NameLast Name
By choosing to participate in the G.I.R.L.S. Club, I agree to:
- Follow all rules and guidelines as outlined by the coordinator, mentee training, program policies, and this contract
- Have a positive attitude and be respectful of my mentor
- Be on time for scheduled meetings or notify the coordinator or mentor at least 24 hours beforehand
- Inform the coordinator of any difficulties or areas of concern that may arise
- Participate in the outings that are scheduled
- Participate in a closure process when I have finished out my commitment
- Notify the coordinator if I have changes in address, email, or phone number
I understand that upon closure, future contact with a mentor is beyond the scope of the G.I.R.L.S. Club and may happen only by the mutual consensus of the mentor, the mentee, and parent/ guardian.*
I agree to follow all of the above stipulations of this program as well as any other conditions as instructed by the coordinator at this time or in the future.
Mentee's Signature:*

Clear
Today's Date*

MonthDayYear

Parent/Guardian Consent & Release Information

Please select a answer after each statement.
I give informed consent and permission for my child to participate in mentoring activities as a member of G.I.R.L.S. Club.*
I agree to have my child picked up promptly following each meeting.*
I am comfortable with my child having contact her mentor on a weekly basis for a minimum of one year.*
I agree to have my child to follow all mentoring program guidelines and understand any violation on my child’s part may result suspension and/or termination of the mentoring relationship.*
My child has permission to be used in public relation materials for the G.I.R.L.S. Club. Examples of these materials include photographs, videos, literature, web pages, and new releases in both traditional and electronic media.*
I will encourage my child to participate in all meetings, workshops, cultural and educational events, and retreats as well as any other opportunities that may not as of yet be scheduled, with the understanding that I will be notified about changes in the schedule.*
I will be responsible for asking questions of my daughter and of the leadership to ensure that the materials used in the program are agreeable to me. *
I understand that all personal information will be kept confidential. *
I understand I must return all of the following completed items along with this application and that any incomplete information may delay the application being processed*
By signing below, I attest to the truthfulness of all information listed on this application and agree to all above terms and conditions.
Parent/Guardian Signature:*

Clear
Today's Date*

MonthDayYear

Contact and Information Release

(To be completed by Parent / Guardian)
Member's Name*

First NameLast Name
School*
Today's Date*

MonthDayYear
I hereby grant permission for G.I.R.L.S. Club to make contact with my child’s school for the purposes ofscreening and interviewing as well as ongoing support of her participation in the mentoring program.

I authorize G.I.R.L.S. Club to obtain any information regarding my child from her teacher including academic and behavioral records and conversations with teachers, counselors, and other administrative staff.

Further, I understand that basic information about my child will be anonymously shared with prospective mentors.

I grant my daughter permission to participate in this exciting mentoring program.
Parent/Guardian's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Signature:*

Clear
Today's Date*

MonthDayYear

Mentee/Parent Contract

(To be completed by Parent / Mentee)
I agree to participate in the G.I.R.L.S. Club Mentoring Program. I understand that the mentor is a volunteer who wants to help me to be a success in school and in life and will act as a friend, advisor, and role model. I also understand that no monetary assistance is provided by the mentor or program.

In return, I agree to:
- Try hard to have a good relationship with the mentor,
- Attend all required program activities;
- Abide by the rules and regulations of the program;
- Communicate with the program coordinator if I feel uncomfortable or experience problems at any time during the program; and
- Fill out a survey at the end of the year.
I understand that if I miss four mentoring sessions or have four late pick-ups I may lose the privilege of participating in the G.I.R.L.S. Club.
Parent/Guardian Signature:*

Clear
Mentee Signature:*

Clear

Parent / Guardian Contract

(To be completed by Parent / Guardian)
Mentee's Name*

First NameLast Name
By allowing my daughter to participate in G.I.R.L.S. Club, I agree to:
- Allow my child to participate in the G.I.R.L.S. Club
- Observe all rules and guidelines and encourage my child to do the same as outlined by the coordinator, mentee training, program policies, and this contract.
- Support my child in the mentorship process by allowing her to meet with mentors at least twice a month during the meetings.
- Support my child by picking her up from the scheduled meetings if transportation is not provided.
- Regularly and openly communicate with the coordinator as requested.
- Inform the coordinator if I observe any difficulties or have areas of concern that arise during mentorship
- Participate in a closure process when that time comes.
- Notify the coordinator if I have any changes in address or phone number.
- Provide the coordinator and the mentor with any additional health insurance information for my child.
I understand that upon closure, future contact with my child and mentors is beyond the scope of the G.I.R.L.S. Club and may happen only by the mutual consensus of the mentor, the mentee, and parent/guardian.*
I understand that the purpose of the G.I.R.L.S. Club mentoring program is to develop my child academically, socially and behaviorally. I understand that participation in the program is vital to the success of my child.*
I agree to follow all of the above stipulations of this program as well as any other conditions as instructed by the coordinator at this time or in the future.
Parent/Guardian Signature:*

Clear
Today's Date*

MonthDayYear
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