Mentee Boys Application – Angel's Helping Hands

Personal Information - Step 1 of 7

We deploy all efforts to protect the private nature of your personal information and all of your personal information will be kept strictly confidential.

Date

Parent/Guardian Name *

Relationship to Mentee:

Mother
Father
Other

Please specify

Street Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Cell Phone

Work Phone

Email *

Mentee’s Name *

Mentee Date of Birth

Age

Gender

Male
Female
Other

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

Please answer all of the following questions as completely as possible.

1. Why do you/your child want to participate in a mentoring program?

2. Briefly describe your expectations of the mentoring program?

3. Is your child available to meet with a mentor a minimum of one hour per week either in-person, via Zoom, FaceTime, or via telephone call?

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? If so, please describe your child’s 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 child 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 for 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?

Name of Primary Care Physician

Phone Number

Medical Insurance Provider:

(For outing purposes only)

Policy Number

Phone Number

Does your child have any physical problems or limitations?

Is your child receiving treatment for any medical issues?

Is your child currently taking any type of medications?

Please Explain

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

Please Explain

Does your child have any emotional issues right now?

Please Explain

Is your child currently seeing a counselor or therapist?

Please Explain

We appreciate you and your child’s interest in her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their child to participate in the mentoring program. After receiving this completed application from you, we will evaluate the information and send you an email letting you know if your child has been accepted into the mentoring program. The information that you provided in this application 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 upon anonymous information provided about each other.

Please check each of the following boxes:

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 of 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
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 of 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
• Contact and Information Release Form
• 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

Type your name above

Date

I understand that checking this box constitutes a signature confirming that I have read, understood, and accept the contents herein. *

I understand

Mentee Name

Date

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.

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

Type your name above

Date

I understand that checking this box constitutes a signature confirming that I have read, understood, and accept the contents herein. (copy) *

I understand

Parent Name

Address

Address Line 1

City

State

Zip Code

Cell Phone:

To Be Signed by the Mentee and Parent/Guardian

1. Be dependable and punctual! If you will be late or absent, please notify the mentor as soon as possible.
2. Never put yourself into situations that could be perceived as inappropriate. Meet in public places as much as possible. Never be in a home alone with your mentor.
3. Absolutely NO sharing of information on social media sites!
4. Refer concerns to your guardian/contact person.
5. Never take any kind of medication from a mentor.
6. Smoking, drinking or drug use is not permitted while with a mentor.
7. Respect mentors’ privacy. When meeting and talking with mentor in public, avoid talking about private matters where others can hear.
8. Respect cultural and social differences and religious beliefs. Do not try to change them, but instead accept them as they are. Avoid imposing your own upon them.
9. Do not travel with your mentor without written consent from your parent/guardian.
10. Make any promises sparingly and keep them faithfully.
11. Mentor/mentee assignments may be changed if either the mentor or mentee request it.
12. Please do not carry weapons of any kind when spending time with your mentor.

By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

Mentee Signature

Type your name above

Date

I understand that checking this box constitutes a signature confirming that I have read, understood, and accept the contents herein. *

I understand

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

Type your name above

Date

I understand that checking this box constitutes a signature confirming that I have read, understood, and accept the contents herein. *

I understand

To Be Signed by the Mentee and Parent/Guardian

• Commit to participate in the Mentorship Program for a minimum of nine (9) months and dedicate 4-6 hours a month from the time you accepted into the program.
• Attend monthly workshops and engage in mentoring activities via in-person, zoom, or phone call.
• Commit to the “SONS PLEDGE”.
• Assume responsibility for acquiring or improving skills and knowledge.
• Discuss individual development planning with the mentor.
• Be open and honest on goals, expectations, challenges, and concerns so others can help you.
• Prepare for meetings, actively listen, and ask questions.
• Seek advice, opinion, feedback, and direction from your mentor.
• Be receptive to constructive criticism/feedback and ask for it.
• Keep your conversations confidential.
• Respect your mentor’s time and resources.
• Stay accessible, committed, and engaged during the length of the program.
• Respectfully give feedback to your mentor on what is working or not working in the mentoring relationship.
• Let the Vice President know as soon as possible if you are having a problem connecting with your mentor.

By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions. (To Be Signed by the Mentee and Parent/Guardian)

Mentee Signature

Type your name above

Date

I understand that checking this box constitutes a signature confirming that I have read, understood, and accept the contents herein. *

I understand

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

Type your name above

Date

I understand that checking this box constitutes a signature confirming that I have read, understood, and accept the contents herein. *

I understand

Parent/Guardian Name

Date

By allowing my child to participate in Angel’s Helping Hands Mentorship Program, I agree to:
• Allow my child to participate in the Angel’s Helping Hands Mentorship Program and to be matched with a mentor.
• Follow and encourage my child to follow all rules and guidelines as outlined by the program.
• Support my child in this match by allowing him to meet with his mentor have continuous contact with him for the duration of the mentor-mentee relationship.
• Support my child being on time for scheduled meetings or have him call the mentor at least 24 hours beforehand if unable to make a meeting.
• Maintain open lines of communication with the mentor.
• Check-in monthly with the Vice President about my perspective on my child’s match, and regularly and openly communicate with the program manager as requested.
• Inform the program manager if I observe any difficulties or have areas of concern that may arise in the mentor-mentee relationship.
• Participate in a closure process when that time comes.
• Notify the program manager if I have any changes in address or phone number.
• Provide the program manager and the mentor with any updated health insurance information for my child.

I understand that upon match closure, future contact between my child and his mentor is beyond the scope of the Angel’s Helping Hands Mentorship Program and can happen only by the mutual consensus of the mentor, the mentee, and myself. *

I understand

I agree to follow all the above stipulations of this program as well as any other conditions as instructed by the program manager at this time or in the future. *

I Agree

Parent/Guardian Signature

Type your name above

Date

I understand that checking this box constitutes a signature confirming that I have read, understood, and accept the contents herein. *

I understand

Name