Mentee Application

Student Application

* Required field
Basic Information
* First Name
Middle Name
* Last Name
Date of Birth
Contact Information
Mobile Phone
T-Shirt Size
Student ID Number
Demographic Information
* Gender
* Other Ethnicity
Primary Language
Other Primary Language
Secondary Language
Other Secondary Language
Medical Information
Medical Conditions
Medical Conditions Allergies
Medical Conditions Others
Additional Information
Types of Challenges
Challenges Other
Challenges Behavior Other
Description of Challenge
Mentee From Home With a History of
Special Populations
Address Information
Address 1
Address 2
Zip Code
Other Information
Family Household Income
Household Size
Family Structure
* Other Family Structure
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Referral Information
Referral Source
* Other Referral Source
Emergency Contact Information
Primary Emergency Contact
PEC Name
PEC Relationship
PEC Home Phone
PEC Mobile Phone
PEC Work Phone
PEC Work Phone Ext
Primary Emergency Contact Email
Secondary Emergency Contact
SEC Name
SEC Relationship
SEC Mobile Phone
SEC Home Phone
SEC Work Phone
SEC Work Phone Ext
Secondary Emergency Contact Email
Program Questions
* Does your family receive FCDJFS Benefits?
* Is student currently in Foster Care?
* Does student receive Medicaid - Health/Medical Assistance?
* Does your Family receive Supplemental Nutrition Assistance Program - Food Assistance?
* Does student receive Ohio Works First - Cash Assistance?
If qualifying based on income, please select one of the following Household Financial Income Levels
* School Student will be attending in the fall
* Is student scheduled to participate in any additional summer camps?
Electronic Signature
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I hereby authorize my child to participate in the All THAT Summer Workforce Development program and grant All THAT staff permission to discuss my child's performance with Eckerd Workforce Development and Columbus and Whitehall City School staff as it relates to attendance, performance and behavioral issues for the 2017 - 2019 school years.  All THAT will communicate regularly with school administration and I understand that All THAT's use of student information is solely for educational purposes and will remain confidential.  

I understand that communication regarding additional paperwork needed for enrollment in the Summer Program will be communicated via email and/or text.  

I understand that completing this application does not constitute an offer of employment.