Harvest Youth Mentoring
Email address *
Parent/Guardian Name *
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Parent/Guardian Telephone/Cell Phone *
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Family Address *
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Mentee's First Name *
Your answer
Mentee's Last Name *
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Mentee's Date of Birth *
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YYYY
Mentee's Grade *
Mentee's School *
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Mentee's Gender *
List any medical, concerns, mental health conditions or allergies (write n/a if not applicable) *
Your answer
Note any involvement with social services or the judicial system (write n/a if not applicable) *
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Interests, hobbies, or activities you enjoy: *
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Finish the sentence below. No answer is right or wrong
I really feel connected when *
Your answer
I really feel angry when *
Your answer
I really feel joyful when *
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A job or task that I really enjoy is *
Your answer
What is the most important thing that you think your we should know about you? *
Your answer
Please read carefully!
Please read carefully!
By submitting below, you consent for your child to participate in Harvest Youth Mentoring and affirm that you have read and agree to the Consent Form and Release and Indemnity Agreement.
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