Project MotiVATe: Mentee Applicant Information
In order for a potential mentee to be considered, students must be:

• Between the grades of 8th to 11th
• Vietnamese-American
• In need of assistance to develop academic, social and cultural skills

Full Name *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Country of Birth *
Your answer
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
High School *
Your answer
Year/Grade in School
GPA *
Your answer
Extracurricular Activities and Hobbies
Your answer
Mother's Name *
Your answer
Mother's Email Address
Your answer
Mother's Home Phone *
Your answer
Mother's Cell Phone
Your answer
Mother's Occupation *
Your answer
Father's Name *
Your answer
Father's Email Address
Your answer
Father's Home Phone *
Your answer
Father's Cell Phone
Your answer
Father's Occupation *
Your answer
Family Income *
How many people live in your household? *
How many siblings does your son/daughter have, and what are their ages & genders? *
Your answer
Has your child ever been involved in disciplinary issues at school? If yes, please describe. *
Your answer
Has your child been diagnosed with any learning disability (ADD, ADHD, etc.)? If yes, please describe. *
Your answer
To your knowledge, has your child ever used drugs or alcohol? *
Your answer
Who is filling out this application (Mentee, Mom, Dad, Sister, Counselor, etc)? *
Your answer
When are you available for an interview (evenings, weekends, etc)? *
Your answer
How did you hear about Project MotiVATe? *
Your answer
Additional Comments
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Project MotiVATe. Report Abuse - Terms of Service - Additional Terms