Mentee Application

If you would like to enroll your child in our Youth Mentoring Program, please complete the Mentee Application and submit it to Children's Aid Society. If you have any questions while completing the application, please contact Jenna at (814) 765-2686 x209.

* Required field
Basic Information
* First Name
Middle Name
* Last Name
Date of Birth
Contact Information
Mobile Phone
Custom ID
T-Shirt Size
Demographic Information
* Gender
* Other Ethnicity
Medical Information
Medical Conditions
Medical Conditions Allergies
Additional Information
Types of Challenges
Mentee From Home With a History of
Counseling Information
Address Information
Zip Code
Other Information
Family Household Income
Participates in free/reduced lunch
Household Size
Family Structure
* Other Family Structure
Career Focused Interests
Interests Other
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Referral Information
Referral Source
* Other Referral Source
Referral Comments
Referral Date
Reason for Referral
Emergency Contact Information
Primary Emergency Contact
PEC Name
PEC Relationship
PEC Home Phone
PEC Mobile Phone
PEC Work Phone
PEC Work Phone Ext
Secondary Emergency Contact
SEC Name
SEC Relationship
SEC Mobile Phone
SEC Home Phone
SEC Work Phone
SEC Work Phone Ext
Program Questions
* Parent/Guardian
* Is there a person who shares legal custody of this child?
* Do you have legal custody of the child?
* If yes, are they aware and supportive of the child's enrollment in the program?
* Name
* Phone Number
* Child's School
* Grade
* Parent Place of Employment
* Parent Work Phone Number
* May we contact you (the parent/guardian) at the work number?
* Check the best number and time to contact you (the parent/guardian)
* What is the primary reason for you wanting your child to participate in the program?
* Does your child have siblings or relatives who are applying for the program at this time or who are currently in the program?
* Do you anticipate any significant life changs over the next year or have you had any in the past year, such as moving?
* Wil your child be able to meet with their mentor at least two times a month for four hours?
* Does your child have a parent/guardian with current or past military experience?
* Does your child have a parent/guardian who is currently incarcerated?
* Has your child ever been arrested or involved in the juvenile justice system?
* Within the last year, has your child been in any trouble at school?