NFBTX Minor Mentee Application Form
This form must be completed by both the mentee and his/her parent or guardian. The required approval must be provided by the parent or legal guardian. If you are over the age of 18, please use the adult application. It can be found on our website. Or, our program staff can provide the appropriate link upon request. If you have difficulty completing this application, please call our mentoring program staff at 281-968-7684.
Name (First, Middle, Last) *
Street Address *
City *
State *
ZIP
County *
Phone Number *
E-Mail Address
Date of Birth *
MM
/
DD
/
YYYY
Please check the appropriate items below.
Gender *
Required
With which of the following ethnic groups do you most closely identify? *
Required
If you marked "other" for above, please specify here. *
What is the cause of your blindness or low vision? (Glaucoma, Retinitis Pigmentosa, ROP, other) *
What is your visual acuity? *
Give us your acuity in both eyes if you know it. Acuity is usually stated in the form 20/20. If you don't know your visual acuity, please respond by writing the words not known in the space for this question.
Please list your field loss, if any. *
Some eye diseases cause a loss in field vision. If you have a field loss, please list the degree of field you currently have. Field is usually written in degrees. So, if your field is restricted in some way, list that here. If you don't have a field loss, just write the word none in this space.
Please list any additional disability/disabilities (if appropriate). *
Are you currently attending school? *
Required
If in school, which school do you currently attend? *
Please check the highest level of education you have successfully completed. *
Required
Degree completed (if applicable):
Are you currently employed? *
Required
If yes, who is your employer? *
Give your job title and a brief summary of your responsibilities:
What is your career goal or career interest?
Please list all organizations with which you are currently affiliated and active. Please be sure to include civic, community, social, etc. *
Is there anyone you would recommend to participate in this mentoring program? If so, please provide his or her name and contact information:
Please read this carefully before signing:
The National Federation of the Blind of Texas Mentoring Program appreciates your interest in becoming a mentee.

Much of the information you supply in this application will be used to match you with an appropriate mentor. Therefore, the mentoring staff at times may 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 initial interest from the mentee, parent/guardian, and mentor based first upon anonymous information provided about each other.
If you are under the age of 18, please have your parent or guardian complete the following.
Please initial each of the following if you are granting consent:

(Optional) I agree to allow the NFB TX mentoring program to use any photographic image of my child while participating in the mentoring program. These images may be used in promotions or other related marketing materials.
I give my informed consent and permission for my child to participate in the National Federation of the Blind of Texas Mentoring Program and its related activities. *
I agree to have my child follow all mentoring program guidelines and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship. *
General program guidelines include the following: active participation in the program for a two-year period, participation in at least three group activities annually, maintaining regular contact with the assigned mentor, communicating effectively with program staff, abstaining from drugs and alcohol during all program activities, and working toward the set of goals established by the mentoring team. Additional, written guidelines will be provided to all program participants prior to assigning a mentor. If at any time the mentee decides that they are unable or unwilling to adhere to the specific guideline set forth here and in other program documents, they will have the opportunity to withdraw from the program.
I hereby acknowledge that my child will be transported by his/her mentor and/or NFBTX program staff or representatives while participating in the program and that such transportation is voluntary and at my own risk. *
I release the National Federation of the Blind of Texas mentoring program of all liability of injury, death, or other damages to me, my child, my family, estate, heirs, or assigns that may result from my child’s participation in the program, including but not limited to transportation, and hold harmless any program 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 the NFBTX mentoring program to use any photographic image of my child while participating in the mentoring program. These images may be used in promotions or other related marketing materials. *
Required
Please provide the following information related to medical history.
Name of primary care physician:
Phone number of primary care physician:
Medical insurance provider:
Policy number:
Phone number:
Does your son/daughter have any physical problems or limitations? If yes, explain.
Is your son/daughter currently receiving treatment for any medical issues? If yes, explain.
Is he/she currently on any type of medications? If so, please specify.
Does your son/daughter have any known allergies or adverse reactions to medications? If yes, please describe them below:
Does your son/daughter have any emotional issues or problems right now? If yes, explain.
Therapist's name:
By signing below, I attest to the truthfulness of all information listed on this Application and agree to all the above terms and conditions. I give permission for my child to participate in the NFB TX mentoring program.
Parent/guardian signature *
Typing your name in this space serves as a digital signature for purposes of this program.
Date
Address (Parent)
City (Parent)
State (Parent)
ZIP (Parent)
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