Mentee Application

Tandem Mentorship 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 Tandem Mentorship Program. Please have your child help fill out their interests at the bottom of this application. 

Much of the information 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.

After receiving this completed application from you, we will evaluate the information and send you a letter letting you know if your child has been accepted into the mentoring program. 

 

* - Required field
Basic Information
* First Name
* Last Name
Date of Birth
Contact Information
Mobile Phone
Phone
Email
Basic
T-Shirt Size
Demographic Information
* Gender
Ethnicity
* Other Ethnicity
Additional Information
Mentee From Home With a History of
Address Information
Address 1
City
State
Zip Code
Country
Availability
Before School Availability
AM Block Availability
Lunch
After School Availability
PM Block Availability
Other Information
Family Structure
* Other Family Structure
Emergency Contact Information
Primary Emergency Contact
PEC Name
PEC Relationship
PEC Home Phone
PEC Mobile Phone
PEC Work Phone
Primary Emergency Contact Email
Secondary Emergency Contact
SEC Name
SEC Relationship
SEC Mobile Phone
SEC Home Phone
SEC Work Phone
Secondary Emergency Contact Email
Program Questions
* Is your youth currently in a counseling relationship or has had counseling in the past? If yes, are you (parent/guardian) interested in sharing information about counseling history with the program director or future mentor?
* Please list any challenges your youth may be facing right now. (academic, behavioral, personal, skills, ect.) Is he/she self-aware of his/her own challenges?
* How did you hear about Tandem?
* Youth: Please list some of your interests as well as some activities you would like to do with your mentor
* Youth: Do you believe that there is a God? Do you believe in Jesus?
* Medical Information: Please write the name of your child's primary care physician, phone number, and insurance provider.
Electronic Signature
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Please read this carefully before signing

  • I give my informed consent and permission for my child to participate in the Tandem Mentorship Program and its related activities. ­­­­­­­­­­­­
  •  I hereby acknowledge that my child will be transported by his/her mentor and/or Tandem staff or representatives while participating in the Tandem Mentorship  Program, and that such transportation is voluntary and at his/her own risk.
  •  I release the Tandem Mentorship Program of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any  Tandem 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 agree to allow Tandem Mentorship Program (513free, Inc.) to use any photo, video, or audio of my child taken while participating in the mentoring program. These images, footage, or audio may be used in promotions or other related marketing materials.

School Contact and Information Release

  • I hereby grant permission for Tandem Mentorship Program to make contact with my child and conduct a personal interview for the purposes of applying to be a mentee.  Tandem may also make contact with my child on school premises for the purposes of screening and interviewing as well as ongoing support of his/her participation in the mentoring program. 
  • I authorize Tandem to obtain any needed information regarding my child from his/her school staff, including academic and behavioral records and conversations with teachers, counselors, and other administrative staff.
  • I authorize that non-identifying information may be gathered about program participants and shared with other participants, individuals, or organizations.
  • 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, my 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, I attest to the truthfulness of all information listed on this application and agree to all the above terms and condition