Youth Mentee Application

Personal Information (To Be Completed by Parent/Guardian)

Youth's First Name

Youth's Middle Name

Youth's Last Name

Name of Parent/Guardian

Relationship to Youth

Youth's Date of Birth

Youth's Gender

Ethnicity

Name of School

Grade

Street Address

City

State/Province

Code

Home Phone Number

Child's Mobile/Pager Phone Number(s)

Parent’s Mobile/Pager Phone Number(s)

Child’s Email Address:

Parent's Email Address

Emergency Contact Name

Emergency Contact Phone Number

Upload youth's photo

Please List all members of your household

Name	Gender	Age	Relationship with Mentee

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

Briefly describe your expectations of the mentoring program?

Is your child available to meet with a mentor a minimum of one hour per week? Yes No

Please explain any particular scheduling issues that you may have

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 problems either at home or at school? If yes, provide details

Has your child experienced any traumatic events (i.e. death in the family, abuse, divorce)?

Can you provide any additional background information that may be helpful in matching your son/ daughter with an appropriate mentor?

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

Is there anyone your child should not have contact with?

(To Be Completed by Mentee)

Why do you want a mentor?

What kind of person would you like your mentor to be?

What are three words that would best describe you?

Please describe three things that you are good at

Is there anything that you would change about yourself?

What clubs, activities, or sports are you in now? How much of your time do these activities take up?

What kind of activities would you like to do with the Youth Mentor Program?

Is there anything else that you would like to describe about yourself that may help us find the best mentor for you?

We will do our best to match you with a mentor who has similar interests and who we think will be a good role model for the upcoming 6 yearS. You should meet with your mentor bilaterally at least once a year for at least 7 days ( these can be taken all at once or in sections) and attend the mandatory module each year with AYMN. The AYMN team will let you know the times and dates of these fun events. To gain the most from the program, you need to make an effort just like the mentor. Please answer the following questions:

Will you try your best to meet with your mentor every year? Yes No

Will you try your best to attend all 6 modules in the next six years? Yes No

Medical History

Name of Primary Care Physician

Phone Number

Medical Insurance Provider

Policy Number

Phone Number

Does your son/daughter have any physical problems or limitations? Yes No

Is your son/daughter receiving treatment for any medical issues? Yes No

Is he/she currently taking any type of medications?

Does your son/daughter have any known allergies or adverse reactions to medications?

Does your son/daughter have any emotional issues right now?

Is your son/daughter currently seeing a counselor or therapist?

Please read the Consent Form Carefully before submitting your application

I have read the Consent Form form, and I agree to terms contained therein.