Angel’s Helping Hands Mentorship Program

MENTEE APPLICATION

(To Be Completed by Parent/Guardian)

Personal Information

Date_____________________

Parent/Guardian Name__________________________________________________________________

Relationship to Mentee: _____Mother _____Father Other (please specify) _______________________

Street Address: _____________________________________________________________________________

City: _________________________________ State: ______ Zip: _______________

Cell Phone: ___________________________ Work Phone: _________________________

Email: _______________________________________

Mentee’s Name_____________________________________________________

Mentee Date of Birth: ____________________ Age: ______________ Gender: ____Male ____Female

Ethnicity: ____African American ____Hispanic ____White ____Asian ____Other (please specify) ______________

Name of School: ____________________________________________________________

Grade: _________

Emergency Contact Name: _____________________________

Emergency Contact Phone Number: _______________________

Please list all members of your household.

Name, Gender, Age, Relationship to Applicant

1.

2.

3.

4.

5.

6.

7.

Please answer all the following questions as completely and truthfully as possible. The answers to these questions will help us in the matching process of a mentor.

1. Why do you/your child want to participate in a mentoring program? Group, One-On-One, or Both?

2. Briefly describe your expectations of the mentoring program.

3. Is your child available to meet with a mentor for a minimum of one hour per week either in-person, via Zoom, FaceTime, or via telephone call? ____Yes ____ No

Please explain any scheduling issues that you may have.

_____________________________________________________________________________________

4. Describe your child’s school performance including grades, homework, attendance, behaviors,

etc.

5. Does your child have friends? Please describe his/her friendships.

6. Is your child currently having problems either at home or at school? If yes, provide details.

7. Has your child experience any traumatic events (i.e. death in the family, abuse, divorce)? If yes,

please provide details.

8. Can you provide any additional background information that may be helpful in matching your

daughter with an appropriate mentor? (Anything that we should be aware of that could be a trigger

for you or your child.)

9. Do you have any religious preferences you would like us to take into consideration?

10. Is there anyone your child should not have contact with?

11. Did your child participate in Angel’s Helping Hands last program cycle as a mentee? If so, how was your experience?

Medical History

Name of Primary Care Physician: _________________________ Phone Number:___________________

Medical Insurance (For outing purposes only) Provider:__________________________________________________________________

Policy Number:_____________________________________ Phone Number:_________________________

Does your child have any physical problems or limitations? ____Yes _____No

Is your child receiving treatment for any medical issues? ____Yes ____No

Is your child currently taking any medications? ____Yes ____No

If yes, please explain________________________________________________________________________

Does your child have any known allergies or adverse reactions to medications?

If yes, please explain________________________________________________________________________

Does your child have any emotional issues right now? _____Yes _____No

If yes, please explain________________________________________________________________________

Is your child currently seeing a counselor or therapist? ____Yes _____No

If yes, please explain________________________________________________________________________

Contact and Information Release

I hereby grant permission for Angel’s Helping Hands Mentorship Program to make contact with my child and conduct a personal interview for the purpose of applying to be a mentee. Further, I understand that basic information about my child will be anonymously (without names) shared with a prospective mentor(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, me and my child’s identity and other relevant information will be shared with the mentor to the extent it aids in facilitating a successful match.

__________________________________________ __________________________

Parent/Guardian Signature Date

Please read this carefully before signing

We appreciate you and your child’s interest in participating in our mentoring program. This application serves to inform parents/guardians about the program and to obtain consent for your child’s participation. Once your completed application is received, our team will carefully review the information provided. You will be notified by email regarding your child’s acceptance into the program. If accepted, the information collected will be used to thoughtfully match your child with an appropriate mentor.

To support a successful mentoring match, program staff may access and, when appropriate, share relevant application information with prospective mentors or other involved parties. Please note that all identifying information remains confidential. Names and identifying details are not shared until there is mutual interest and agreement from the mentee, parent/guardian, and mentor based on anonymized information.

Please INITIAL each of the following:

____ I give my informed consent and permission for my child to participate in the Angel’s Helping Hands

Mentorship Program and its related activities.

____I agree to have my child follow all the 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 hereby acknowledge that my child may be transported by her mentor while participating in

the mentorship program, and that such transportation is voluntary and at her own risk.

____ I release the Angel’s Helping Hands Mentoring Program of all liability of injury, death, or damages to me, my child, family, estate, heirs, or assigns that may result from her participation in the program,

including but not limited to transportation, and hold harmless any mentor, program staff, or other

representatives, both collectively and individually, of any injury, physical or emotional, other than

where gross negligence has been determined.

I understand that I must return all the following completed items along with this application, and

that any incomplete information will result in the delay of this application being processed:

• Signed application

• Mentee Guidelines/Instructions Form

• Mentee Expectations Form

• Parent/Guardian Agreement 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 Date