Mentee Application (To Be Completed by the Parent/Guardian) Personal InformationYouth’s Name: Date MM slash DD slash YYYY Parent/Guardian Name: Relationship to Youth Mother Father Other Specify: Street Address: City: State: Zip: Home phone:Work phone:Date of Birth MM slash DD slash YYYY Age:Gender Male Female Ethnicity: White Hispanic African American Asian Other Other Name of School: Grade: Emergency Contact Name:Phone Number:Application QuestionsPlease answer all of the following questions as completely as possible. If more space is needed, use an extra sheet of paper or write on the back of this page.Why do you/your child want to participate in a mentoring program? Briefly describe your expectations for the NMI: Is your child available to meet with a mentor two times per month for a minimum of one year? Please explain any particular scheduling issues. Is your child willing to attend an initial mentee training session and two training sessions per year after being matched? Describe your child’s school performance including grades, homework, attendance, behaviors, etc.: Does your child have friends? Please describe his/her friendships. Is your child currently having any problems either at home or school? Has your child experienced any traumatic events (i.e., death in the family, abuse, divorce)? If yes, please provide details. Can you provide any additional background information that may be helpful to NMI in matching your son/daughter with an appropriate mentor? Please read this carefully before signingNMI appreciates you and your child’s interest in his/her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their son/daughter to participate in the NMI. Please initial each of the followingI give my informed consent and permission for my child to participate in the NMI and its related activities. I give my informed consent and permission for my child to participate in the NMI 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. 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. (optional) I agree to allow NMI to use any photographic image of my child taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials. (optional) I agree to allow NMI to use any photographic image of my child taken 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. Parent/Guardian SignatureDate MM slash DD slash YYYY
