Youth Mentee Application Form

Confident Girl Mentoring Program, Inc.

Youth Mentee Application

Confident Girl Mentoring is a fast-growing nonprofit organization that is committed to girls excellence. We work with girls, parents and caregivers, and stakeholders to ensure lasting impact through teaching advocacy, leadership, guidance, social-emotional intelligence, assertive self-expression and healthy relationships, giving girls the skills and confidence to thrive as leaders.

Date: *

Date

Which Session?: *

Ages 7-12 Wednesday, 4:00 -5:30pm Ages 13-19 Friday, 4:00 -5:30pm

Are you available any other days/times? (If yes, please note) *

Youth's Name: *

First Name Last Name

Parent/Guardian Name: *

First Name Last Name

Relationship to Youth: *

Birth Date: *

Month Day Year

Ethnicity: *

Name of School: *

Grade: *

Street Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number: *

Area Code Phone Number

E-mail Address: *

Emergency Contact Name: *

First Name Last Name

Phone Number: *

Area Code Phone Number

How were you referred to us? *

Internet Website Social Media Word of Mouth School Referral

Write a brief statement on why you want your child to participate in a mentoring program? *

Briefly describe your expectations of the mentoring program? *

Describe your child's school performance including grades, homework, attendance, behaviors, etc. *

Has your child experienced any traumatic events (i.e death in the family, abuse, divorce, change in social norms)? If yes, please provide any details. *

Is there anything that we should be aware of that could be a trigger for your child ? *

Do you have any religious preferences you would like for us to take into consideration? *

Is there anyone your child should not have contact with? *

Does your child have any medical problems or limitations (i.e allergies, emotional issues, physical problems or limitations)? If yes, please explain *

Mentee Release Statement

I, the undersigned, hereby state that if my child's is accepted as a menteer, I agree to abide by the rules and regulations of the Confident Girl Mentoring Program, Inc. I understand that the program involves spending a minimum of one hour/week for 12 weeks at the assigned location or virtually. Further, I understand that my child will attend at least 85% of program and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship. I hereby acknowledge that my child may be transported by his/her mentor while participating in the mentorship program, and that such transportation is voluntary and at his/her own risk.

Further, I hereby fully release, discharge, and hold harmless the Confident Girl Mentoring Program, Inc. participating organizations, and all of the foregoing employees, officers, directors, and coordinators both collectively and individually from any and all liability, claims, causes of action, costs and expenses that may be or may at any time hereafter become attributable to my participation in the Confident Girl Mentoring Program, Inc.

Photo/Video Release

I, authorize Confident Girl Mentoring Program, Inc. and its agents and employees the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, or members of my family, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I hereby release Confident Girl Mentoring Program, Inc. and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview or guest lecture, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.

Parental/guardian concerns with this policy should be contact Confident Girl Mentoring Program's Director at support@confidentgirlmentoring.com

Youth Mentee Guidelines/ Instructions

1. Be dependable and punctual! If you will be late or absent, please notify the mentor as soon as possible.

2. Never put yourself into situations that could be perceived as inappropriate. Meet in public places as much as possible. Examples— Never be in a home alone with your mentor. Never be
in a bedroom or bathroom with you mentor.

3. Absolutely NO photos or sharing of information can be shared on social media sites without prior approval!

4. Refer concerns to your guardian/contact person.

5. Never take any kind of medication (i.e., aspirin) from a mentor.

6. Smoking, drinking or drug use is not permitted while with a mentor.

7. Respect mentors privacy. When meeting and talking with mentor in public, avoid talking about private matters where others can hear.

8. Respect cultural and social differences and religious beliefs. Do not try to change them, but instead accept them as they are. Avoid imposing your own upon them.

9. Do not travel with your mentor without written consent from your parent/guardian.

10. Make any promises sparingly and keep them faithfully.

11. Mentor/mentee assignments may be changed if either the mentor or mentee request it.

12. Please do not carry weapons of any kind when spending time with your mentor.

I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States. *

Yes No

Signature *

Clear