Mentee Application

Mentee Application
(To Be Completed by the Parent/Guardian)
Youth's Name
Date
MonthDayYear
Date
Parent/Guardian Name
Relationship to Youth:
MotherFatherOther
Other, specify
Street Address
City
State
Zip
Home Phone
Work Phone
Youth Social Sec. #
Date of Birth
MonthDayYear
Date
Age
Gender
Ethnicity
African AmericanAsianWhiteHispanicOther
Name of School
Grade
Emergency Contact Name
Phone Number
Please list all members of your household.
Name of household member Gender Age Relationship to Apllicant
1
2
3
4
5
6

Application Questions
Please answer all questions as completely as possible.
1. Why do you/your child want to participate in a mentoring program?
2. Briefly describe your expectations for the Motherless Daughters Foundation Mentoring Program
3. Is your child available to meet with a mentor eight hours per month and have contact a least once a week for a minimum of one year? Please explain any particular scheduling issues.
4. Is your child willing to attend an initial mentee training session and two training sessions per year after being matched?
5. Describe your child's school performance including grades, homework, attendance, behaviors, etc.
6. Does your child have friends? Please describe his/her friendships.
7. In your child currently having any problems either at home or school?
8. Has your child experienced any traumatic events (i.e., death in the family, abuse, divorce)? If yes, please provide details.
9. Can you provide any additional background information that may be helpful to Motherless Daughters Foundation in matching your son/daughter with an appropriate mentor?
Medical History
Name of Primary Care Physician
Phone No.
Medical Insurance Provider
Policy Number
Phone No.
Does your son/daughter have any physical problems or limitations?
Is your son/daughter currently receiving treatment for any medical issues?
Is he/she currently on any type of medication? Is so, please specify.
Does your son/daughter have any allergies or adverse reactions to medications? If yes, please describe them below:
Does your son/daughter have any emotional issues or problems currently?
Is your son or daughter currently seeing a counselor or therapist?
Therapist's Name
Please read this carefully before signing
Motherless Daughters Foundation Mentoring Program 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 Motherless Daughters Foundation Mentoring Program.
After receiving this completed application from you, we will evaluate the information and send you a let- ter letting you know if your child has been accepted into the mentoring program. Much of the informa- tion you supply in this application packet will be used to match your child with an appropriate mentor. Therefore, the mentoring staff may, at times, 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 an initial interest from the mentee, parent/guardian, and mentor based first upon anonymous information provided about each other.
(optional) I agree to allow Motherless Daughters Foundation to use any
Initial I give my informed consent and permission for my child to participate in the Motherless Daughters Foundation Mentoring Program and its related activities.
1 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.
2 I release the Motherless Daughters Foundation Mentoring Program of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from participation in the program, including but not limited to transportation, and hold harmless any Motherless Daughters Foundation mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.
3 (optional) I agree to allow Motherless Daughters Foundation 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.
I understand I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of this application being processed.
- Contact and Information Release Form
- Interest Survey Form
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 Signature
Clear
Date
MonthDayYear
Date
Should be Empty:

	Name of household member	Gender	Age	Relationship to Apllicant
1
2
3
4
5
6

Mentee Application

Application Questions

Medical History