Mentee application 2018
5TH-12TH GRADE GIRLS
Mentee’s Name: *
Your answer
Phone Number *
Your answer
Does the mentee/youth have any physical problems or physical limitations? If so, please specify:
Your answer
Address *
Your answer
Parent Information: Name, Number and Email *
Your answer
Is the mentee/youth currently receiving any medical treatment for any medical conditions? *
Your answer
Does the mentee/youth have any allergies or adverse reactions to medications?
*
Your answer
What are 3 goals you hope the youth achieves in the mentoring program? *
Your answer
Is the youth available to meet or have contact with a mentor once a week? *
Required
Is the youth able to attend educational workshops and community service activities every month? *
Required
Is your child currently having any behavioral or social problems at home or at school? If so, please provide information that may be helpful for us to know as we work with your child. *
Your answer
Can you provide any additional information that may be helpful to the G2D Mentoring Program in matching the mentee with an appropriate mentor? *
Your answer
Do you have a mode of transportation? *
Will you and your youth be available for our first workshop Sept. 21? *
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