Power of Dad Mentoring Program Application
To be completed by the Parent/Guardian
Email address *
Youth's Name: *
Your answer
Parent/Guardian Name: *
Your answer
Relationship to Youth: *
Address: *
Your answer
Phone number: *
Your answer
Youth's Social Sec. #
Your answer
Name of School: *
Your answer
Grade *
Emergency Contact Name: *
Your answer
Emergency Contact Phone #: *
Your answer
Ethnicity
Youth's Date of Birth: *
MM
/
DD
/
YYYY
Please list all members in the household, with age and relationship to youth: *
Your answer
1. Why do you/your child want to participate in a mentoring program? *
Your answer
2. Briefly describe your expectations for the Power of Dad: *
Your answer
3. Is your child available to go through all 3 phases of the POD group mentoring program for the time period of 6 months? Please explain any particular scheduling issues. *
Your answer
4. Describe your child's school performance including grades, homework, attendance, behaviors, etc.: *
Your answer
5. Does your child have friends? Please describe his friendships. *
Your answer
6. Is your child currently having any problems either at home or school? If yes, please explain. *
Your answer
7. Has your child experienced any traumatic events (i.e., death in the family, abuse, divorce)? If yes, please provide details. *
Your answer
8. Can you provide any additional background information that may be helpful to Power of Dad in matching your son with an appropriate mentor? *
Your answer
Comments
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service