Outreach Involvement Center: Mentee Application

General Information

Name:

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Gender:

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Prefer to be called:

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Email:

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Phone Number:

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Cell / Alternative Number:

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Date of Birth:

Address:

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Social Security Number

ex. 123-45-5678

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Age:

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Grade:

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Race:

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Sex:

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Parent / Guardian Name:

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Telephone:

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Lives with in home:

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What languages do you speak?

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What languages do you read?

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School Name:

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What is your favorite subject:

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What is your least favorite subject:

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In case of emergency contact

Address:

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Telephone:

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Relation to applicant:

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Grade:

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School:

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Counselor:

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