Mentee Application

* - Required field
Basic Information
* First Name
Middle Name
* Last Name
Date of Birth
Contact Information
Mobile Phone
Phone
Email
Basic
T-Shirt Size
Student ID Number
Demographic Information
* Gender
Primary Religion
Ethnicity
* Other Ethnicity
Primary Language
Other Primary Language
Secondary Language
Other Secondary Language
Medical Information
Medical Conditions
Medical Conditions Allergies
Medical Conditions Others
Additional Information
Challenges
Types of Challenges
Challenges Other
Challenges Behavior Other
Description of Challenge
Mentee From Home With a History of
Special Populations
Counseling Information
Counseling Start Date
Counseling End Date
Counseling
Address Information
Address 1
Address 2
City
State
Zip Code
Country
Availability
Lunch
After School Availability
Other Information
Family Household Income
Household Size
Family Structure
* Other Family Structure
Career Focused Interests
Interests
Interests Other
Photo
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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
Current High School
Does the student have transportation home at the end of the day?
Electronic Signature
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I hereby authorize my child to participate in the All THAT mentoring program and grant All THAT staff permission to discuss my child's performance as it relates to attendance, academic performance and behavioral issues for the 2017 - 2018 school year.  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.