NFBTX Minor Mentee Application Form
An application form to become a National Federation of the Blind of Texas Minor Mentee
This form must be completed by both the mentee and his/her parent or guardian. The required approval must be provided by the parent or legal guardian.
Name (First, Middle, Last) *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
ZIP
Your answer
County *
Your answer
Phone Number *
Your answer
E-Mail Address
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Please check the appropriate items below.
Gender *
Required
With which of the following ethnic groups do you most closely identify? *
Required
If you marked "other" for above, please specify here. *
Your answer
What is the cause of your blindness or low vision? (Glaucoma, Retinitis Pigmentosa, ROP, other) *
Your answer
What is your visual acuity?
Your answer
Please list your field loss, if any.
Your answer
Please list any additional disability/disabilities (if appropriate). *
Your answer
Are you currently attending school? *
Required
If in school, which school do you currently attend? *
Your answer
Please check the highest level of education you have successfully completed. *
Required
Degree completed (if applicable):
Your answer
Are you currently employed? *
Required
If yes, who is your employer? *
Your answer
Give your job title and a brief summary of your responsibilities:
Your answer
What is your career goal or career interest?
Your answer
Please list all organizations with which you are currently affiliated and active. Please be sure to include civic, community, social, etc. *
Your answer
Is there anyone you would recommend to participate in this mentoring program? If so, please provide his or her name and contact information:
Your answer
Please read this carefully before signing:
The National Federation of the Blind of Texas Mentoring Program appreciates your interest in becoming a mentee.

Much of the information you supply in this application will be used to match you with an appropriate mentor. Therefore, the mentoring staff at times may need to access and share this information with prospective mentors and other parties when it is in the best interest of the match. However, we do not reveal names until there is initial interest from the mentee, parent/guardian, and mentor based first upon anonymous information provided about each other.

If you are under the age of 18, please have your parent or guardian complete the following.
Please initial each of the following if you are granting consent:

(Optional) I agree to allow the NFB TX mentoring program to use any photographic image of my child while participating in the mentoring program. These images may be used in promotions or other related marketing materials.

I give my informed consent and permission for my child to participate in the National Federation of the Blind of Texas Mentoring Program and its related activities. *
Your answer
I agree to have my child follow all mentoring program guidelines and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship. *
Your answer
I hereby acknowledge that my child will be transported by his/her mentor and/or NFBTX program staff or representatives while participating in the program and that such transportation is voluntary and at my own risk. *
Your answer
I release the National Federation of the Blind of Texas mentoring program of all liability of injury, death, or other damages to me, my child, my family, estate, heirs, or assigns that may result from my child’s participation in the program, including but not limited to transportation, and hold harmless any program mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.
Your answer
(Optional) I agree to allow the NFBTX mentoring program to use any photographic image of my child while participating in the mentoring program. These images may be used in promotions or other related marketing materials. *
Required
Please provide the following information related to medical history.
Name of primary care physician:
Your answer
Phone number of primary care physician:
Your answer
Medical insurance provider:
Your answer
Policy number:
Your answer
Phone number:
Your answer
Does your son/daughter have any physical problems or limitations? If yes, explain.
Your answer
Is your son/daughter currently receiving treatment for any medical issues? If yes, explain.
Your answer
Is he/she currently on any type of medications? If so, please specify.
Your answer
Does your son/daughter have any known allergies or adverse reactions to medications? If yes, please describe them below:
Your answer
Does your son/daughter have any emotional issues or problems right now? If yes, explain.
Your answer
Therapist's name:
Your answer
By signing below, I attest to the truthfulness of all information listed on this Application and agree to all the above terms and conditions. I give permission for my child to participate in the NFB TX mentoring program.
Parent/guardian signature *
Typing your name in this space serves as a digital signature for purposes of this program.
Your answer
Date
Your answer
Address (Parent)
Your answer
City (Parent)
Your answer
State (Parent)
Your answer
ZIP (Parent)
Your answer
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