Mentee Application
(To be completed by the parent/guardian)

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 the consent of the parent/guardian to allow their son/daughter to participate in the Tandem Mentorship Program.

Youth's Name *
Your answer
Name of School and Grade *
Your answer
Date of Birth and Age *
Your answer
Gender *
Parent/Guardian Name *
Your answer
Relationship to Youth *
Street Address *
Your answer
Home Phone *
Your answer
Work Phone
Your answer
E-mail *
Your answer
Emergency Contact Name and Number (Other Than Yourself) *
Your answer
Preferred Way to Contact *
Name of Primary Care Physician and Phone Number *
Your answer
Medical Insurance Provider, Phone Number, and Policy Number *
Your answer
Does your son/daughter have any physical problems or limitations? *
Is your son/daughter currently receiving treatment for any medical issues? *
Is he/she taking any type of medication? Is so, please specify. *
Your answer
Does your son/daughter have any known allergies or adverse reactions to medications? If yes, please describe them below: *
Your answer
Does your son/daughter have any emotional issues or problems right now? If yes, please describe below. *
Your answer
Is your son or daughter currently seeing a counselor or therapist? *
Please read this carefully before signing. 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. *
Yes
No
I give my informed consent and permission for my child to participate in the Tandem Mentorship Program and its related activities.
I hereby acknowledge that my child will be transported by his/her mentor and/or Tandem staff or representatives while participating in the Tandem Mentorship Program, and that such transportation is voluntary and at his/her own risk.
I release the Tandem Mentorship Program of all liability of injury, death, or other 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 Tandem mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.
(optional) I agree to allow Tandem to use any photo, video, or audio of my child taken while participating in the mentoring program. These images, footage, or audio may be used in promotions or other related marketing materials.
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and condition. There will be a link to a survey for your child to fill out in the confirmation message after submitting this application. *
Your answer
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