Mentee Application

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Basic Information
* First Name
* Last Name
Date of Birth
Contact Information
Mobile Phone
Phone
Email
Basic
T-Shirt Size
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Demographic Information
* Gender
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Other Gender
Sexual Orientation
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Primary Language
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Other Primary Language
Secondary Language
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Other Secondary Language
Transportation
Public Transit Available
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Medical Information
Medical Conditions
Allergies
Asthma
Diabetes
Rheumatoid Arthritis
Other
Medical Conditions Allergies
Additional Information
Challenges
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Types of Challenges
Academic/School
Academic/School: Attendance
Academic/School: Grades/Performance
Behavior
Behavior: Aggression
Behavior: Anger Management
Behavior: Attention Deficit/Hyperactivity
Behavior: Attitude
Behavior: Delinquency
Behavior: Other
Behavior: Self Control
Behavior: Substance Abuse
Personal
Personal: Anxiety
Personal: Confidence
Personal: Depression
Personal: Isolation/Lack of Support
Personal: Self-esteem
Skills
Skills: Communication
Skills: Social
Other
Description of Challenge
Mentee From Home With a History of
Emotional Abuse
Physical Abuse
Sexual Abuse
Substance Abuse
Counseling Information
Counseling
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Address Information
Address 1
City
State
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Zip Code
Country
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Availability
AM Block Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
PM Block Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Other Information
Participates in free/reduced lunch
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Household Size
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Family Structure
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* Other Family Structure
Career Focused Interests
Business
Education
Government
Health Care
Homemaker
Hospitality/Tourism
Law Enforcement
Legal
Military
Non-Profit
Retired
Technology
Transportation
Other
Interests
Arts/Crafts
Board Games
Community Service/Volunteerism
Computer/video games
Cooking/eating out
Cultural events
Cultural events: Concerts
Cultural events: Museums
Cultural events: Other
Cultural events: Theater
Dance
Drama
Fashion
Movies
Music
Music: Listening to music
Music: Playing an instrument
Music: Singing
Outdoor Activities
Outdoor Activities: Biking
Outdoor Activities: Boating/Canoeing
Outdoor Activities: Fishing/Hunting
Outdoor Activities: Hiking
Outdoor Activities: Ice-Skating
Outdoor Activities: Other
Outdoor Activities: Rollerblading/Skateboarding
Outdoor Activities: Running/Walking
Outdoor Activities: Skiing/Snowboarding
Pets
Reading
Shopping
Sports
Sports: Playing Sports
Sports: Playing Sports: Baseball
Sports: Playing Sports: Basketball
Sports: Playing Sports: Cheerleading
Sports: Playing Sports: Football
Sports: Playing Sports: Golf
Sports: Playing Sports: Gymnastics
Sports: Playing Sports: Hockey
Sports: Playing Sports: Lacrosse
Sports: Playing Sports: Martial Arts
Sports: Playing Sports: Other
Sports: Playing Sports: Soccer
Sports: Playing Sports: Softball
Sports: Playing Sports: Tennis
Sports: Playing Sports: Track/Field
Sports: Playing Sports: Volleyball
Sports: Playing Sports: Wrestling
Sports: Watching Sports
Sports: Watching Sports: Baseball
Sports: Watching Sports: Basketball
Sports: Watching Sports: Cheerleading
Sports: Watching Sports: Football
Sports: Watching Sports: Golf
Sports: Watching Sports: Gymnastics
Sports: Watching Sports: Hockey
Sports: Watching Sports: Lacrosse
Sports: Watching Sports: Martial Arts
Sports: Watching Sports: Other
Sports: Watching Sports: Soccer
Sports: Watching Sports: Softball
Sports: Watching Sports: Tennis
Sports: Watching Sports: Track/Field
Sports: Watching Sports: Volleyball
Sports: Watching Sports: Wrestling
Travel
TV
Writing
Other
Photo
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Referral Information
Referral Source
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* Other Referral Source
Reason for Referral
Emergency Contact Information
Primary Emergency Contact
PEC Name
PEC Relationship
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PEC Home Phone
PEC Mobile Phone
Primary Emergency Contact Email
Secondary Emergency Contact
SEC Name
SEC Relationship
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SEC Mobile Phone
Secondary Emergency Contact Email
Program Questions
Electronic Signature
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I, the undersigned, acknowledge that I have read and understand the objectives and activities of the PATHS program as provided by the Tampa Bay Academy of Hope. I consent to my child's participation in the program and understand that the program will cover topics related to sexual risk avoidance, healthy relationships, and personal development.

I understand that my child's participation is voluntary and that they may withdraw from the program at any time. I acknowledge that the program staff is available to answer any questions I may have about the program's content and activities.

By typing my signature below, I give permission for my child to participate in the PATHS program and consent to the collection of information provided in this application.