NFBTX Adult Mentee Application Form
We accept applicants who are ages 14-22. If you are not yet 18, please use the application for minors. You can find that application on our website. Or, you can call our office and request that we send you the link to that form. If you have difficulty completing this form, we can help. Just call our mentoring program at 281-968-7684.
Name (First, Middle, Last) *
Street Address *
City *
State *
Zip *
County *
Phone Number *
E-Mail Address *
Date of Birth *
Please check the appropriate items below.
Gender *
With which of the following ethnic groups do you most closely identify? *
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? *
If in school, which school do you currently attend?
Please check the highest level of education you have successfully completed. *
Degree completed (if applicable)
Are you currently employed? *
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.
I agree to follow all mentoring program guidelines and understand that any violation on my 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 you and your mentor, upon entering the program. Additional, written guidelines will be provided to all program participants prior to assigning a mentor. If at any time you decide that you are unable or unwilling to adhere to the specific guideline set forth here and in other program documents, you will have the opportunity to withdraw from the program.
I hereby acknowledge that I may be transported by my 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 family,estate, heirs, or assigns that may result from my 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 me while participating in the mentoring program. These images 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 conditions.
Please type your name below. This will serve as a digital signature.
Signature *
Please, sign this document electronically by typing your name in the space below.
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