M2M Mentee Enrollment Form
Rates:
$60 Annual Registration Fee
Today's Date
MM
/
DD
/
YYYY
Mentee Background Data
Mentee's Name
Your answer
Mentee's Race
Mentee's Sex
Mentee's Birthdate
MM
/
DD
/
YYYY
Mentee's Birthplace
City, State, Country
Your answer
Mentee's School
Mentee's Grade & Year of Projected Graduation From High School
Your answer
Mentee's GPA
Your answer
Mentee's Email Address
Your answer
Mentee's Cell Phone Number
Your answer
How long has the mentee lived in the Washington, DC Metro Area?
Is the mentee involved in any extracurricular activities (eg. Sports, YMCA, Student-Government Association)?
If yes, please list.
Your answer
Parent/Guardian Background Data
Parents/Guardian's Full Name
Your answer
Address
Street, City, State, Zip Code
Your answer
Email Address
Your answer
Home Phone
Your answer
Work Phone
Your answer
Cell Phone
Your answer
Emergency Contact
Name, Phone, Relationship to Mentee
Your answer
Neighbor or Relative Who Can Typically Contact You
Name, Phone, Relationship to You
Your answer
Employer
Your answer
Occupation
Your answer
Work Hours
Can you be contacted at work?
In Case of Emergency or Urgent Matter
Marital Status
Spouse's Full Name
If Not Applicable, Write N/A
Your answer
Who has legal custody of the child?
Have you or your child ever received help from a social service agency (eg.Family and Child Services)?
Name of Agency
Your answer
Does your family receive public assistance?
What is your household Income?
Your answer
How many individuals currently live in your household?
Your answer
Absent Parent Data
If Applicable
Full Name
Your answer
Birthdate
MM
/
DD
/
YYYY
Is the absent parent incarcerated?
If yes, please name institution below
Your answer
Phone Number
Your answer
Address
Street, City, State, Zip Code
Your answer
How often does the child see the absent parent?
What is the quality of their relationship with the child?
Has the mentee ever been in trouble with...
Check all that apply. If none, write N/A in blank box
Required
If yes, please explain
Your answer
Does the mentee receive free or reduced lunch?
Please provide SchoolMax District Number
Your answer
Username
Your answer
Password
SchoolMax Login
Your answer
Parent Access Key
Your answer
Mentee's Health
Does the mentee have any health challenges or allergies?
If yes, please list all.
Your answer
Is the mentee currently taking medication?
If yes, please list medications.
Your answer
Has he ever received counseling, therapy, psychiatric treatment, or drug/alcohol abuse treatment?
If yes, please describe including dates.
Your answer
Primary Care Physician
Full Name
Your answer
Physician Contact Information
Phone Number
Your answer
Are you disabled?
Required
Are you in need of special accommodations?
Required
Family Data
Please list all the children currently living in your home.
Name, Sex, Age, Relationship to you
Your answer
Please list all other adults currently living in your home, such as grandparents, other adult relatives, boarders, etc.
Name, Sex, Age, Relationship to you
Your answer
General Information
How did you hear about M2M?
Who referred you to M2M?
Your answer
How does your child feel about the possibility of having a mentor?
Your answer
Why do you think your child needs a mentor?
Your answer
Do you have any preferences about the race or religion of your child’s mentor?
Your answer
Upon acceptance into the program, are there any special skills or resources you posses that may benefit the program?
Digital Signature
I verify that the information I am submitting is accurate and truthful to the best of my knowledge.
Nondiscrimination Policy
Mentoring to Manhood does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, height, weight, physical or mental ability.
Submit
Never submit passwords through Google Forms.
This form was created inside of Community Youth Advance. Report Abuse - Terms of Service - Additional Terms