Tandem's Mentee Application
Tandem Mentorship Program appreciates you and your child's interest in his/her becoming a mentee. This application is intended as a means of informing and gaining your consent to have your child to participate in the Tandem Mentorship Program. Please have your child help fill out their interests at the bottom of this application.

Much of the information 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 first upon anonymous information provided about each other.

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.

Child's Name (First, M, Last) *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's T-Shirt Size *
Child's Gender *
Child's Ethnicity *
Child From Home With a History of... *
Required
Parent's Name (First, M, Last) *
Your answer
Home Address *
Your answer
Phone Number (Home and Mobile) *
Your answer
Email
Your answer
Preferred Method of Communication *
Emergency Contact's Name (First, M, Last) *
Your answer
Emergency Contact's Phone Number *
Your answer
Emergency Contact's Address *
Your answer
Does your child have a disability? *
Type of Disability
Your answer
Availability *
Required
How did you hear about Tandem? *
Required
Is your child currently in counseling or has he/she had counseling in the past? If yes, are you (parent/guardian) interested in sharing information about counseling history with the program director or future mentor? *
Your answer
Please list any challenges your youth may be facing right now (academic, behavioral, personal, skills, ect.). Is he/she aware of his/her own challenges? *
Your answer
Medical Information: Please write the name of your child's primary care physician, phone number, and insurance provider. *
Your answer
Youth: Please write down your interests and a few activities you would like to do with your mentor. *
Your answer
Youth: Do you believe that there is a God? Do you believe in Jesus? *
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms