ALOH Breaking Boundaries Mentoring Program Mentee Application
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Mentee's Name (First, Last) *
Parent / Guardian Name *
Relationship to Youth *
Street Address (City, State, Zip) *
Cell Phone Number *
Mentee's Date of Birth *
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/
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/
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Age *
Gender *
Ethnicity *
Name of School & Grade *
Emergency Contact (Name, Number) *
Please list all members of your household. Include name, gender, age, relationship to applicant. *
Why do you/your child want to participate in a mentoring program? *
Briefly describe your expectations of the mentoring program.
*
Is your child available to meet with a mentor at least once a month for 4 hours?
*
Please explain any scheduling issues that you may have.
*
Describe your child’s school performance including grades, homework, attendance, behaviors,
etc.
*
Does your child have friends? Please describe his/her friendships.
*
Is your child currently having problems either at home or at school? If yes, provide details.
*
Has your child experienced any traumatic events (i.e. death in the family, abuse, divorce)? If yes,
please provide details.
*
Can you provide any additional background information that may be helpful in matching your
daughter with an appropriate mentor? (Anything that we should be aware of that could be a
trigger for you or 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?
*
Name of Primary Care Physician / Number *
Does your daughter have any physical problems or limitations?
*
Is your daughter receiving treatment for any medical issues?
*
Is she currently taking any type of medications? If yes, please explain.
*
Does your daughter have any known allergies or adverse reactions to medications? If yes, please explain.
*
Does your daughter have any emotional issues right now? If yes, please explain.
*
Is your daughter currently seeing a counselor or therapist? If yes, please explain.
*
We appreciate you and your child’s interest in her becoming a mentee in our program.
This application is intended as a means of informing and gaining the consent of the
parent/guardian to allow their daughter to participate in the mentoring program. After receiving
this completed application from you, we will evaluate the information and send you a letter
letting you know if your child has been accepted into the mentoring program.
Much of the information that you supply in this application packet will be used to match your
child with an appropriate mentor. Therefore, the mentoring staff may, at times, 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 an initial interest from the
mentee, parent/guardian, and mentor based upon anonymous information provided about each other.
*
I give my informed consent and permission for my child to participate in the Breaking
Boundaries Mentoring Program and its related activities.
*
I agree to have my child follow all the mentoring program guidelines 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 her mentor while participating in
the mentorship program, and that such transportation is voluntary and at his/her own risk.
*
I release the Breaking Boundaries Mentoring Program of all liability of injury, death, or
damages to me, my child, family, estate, heirs, or assigns that may result from his/her
participation in the program, including but not limited to transportation, and hold harmless any
mentor, program staff, or other representatives, both collectively and individually, of any injury,
physical or emotional, other than where gross negligence has been determined.
*
I understand that I must return all of the following completed items along with this application,
and any incomplete information will result in the delay of this application being processed:
• Signed application
• Contact and Information Release Form
• Youth Mentee Guidelines/Instructions Form
By signing below,
I attest to the truthfulness of all information listed on this application and agree to all of the above terms and conditions.
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