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
Ethnicity
* Other Ethnicity
Primary Language
Other Primary Language
Secondary Language
Other Secondary Language
Transportation
Public Transit Available
Medical Information
Medical Conditions
Medical Conditions Allergies
Additional Information
Types of Challenges
Challenges Other
Description of Challenge
Special Populations
Counseling Information
Counseling
Address Information
City
State
Zip Code
Country
Availability
Before School Availability
AM Block Availability
Lunch
After School Availability
PM Block Availability
Other Information
Family Household Income
Participates in free/reduced lunch
Household Size
Family Structure
* Other Family Structure
Career Focused Interests
Career Focused Interests Other
Interests
Interests Other
Emergency Contact Information
Primary Emergency Contact
PEC Name
PEC Relationship
PEC Home Phone
PEC Mobile Phone
PEC Work Phone
Primary Emergency Contact Email
Program Questions
* Has the parent signed off on the mentoring experience?
* Name of School