Mentee Application

Welcome to the LifeSmart Education mentee application! In order to serve you best, please fill in the following information to the best of your ability. 

* Required field
Basic Information
* First Name
Middle Name
* Last Name
Date of Birth
Contact Information
Demographic Information
* Gender
Address Information
Address 1
Address 2
Zip Code
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
* What school do you attend?
* How long have you been attending this school?
* Please enter your phone number:
Is this a mobile phone?
To whom does the phone belong?
If other, please indicate:
* Would you like to sign up to receive text messages?
* What are your primary reasons for wanting a mentor?
* Who is your role model? Please give a brief description of who they are and how they inspire you.
In what ways do you think a mentor could help you? Please select your first choice.
Please select your second choice.
When do you plan on graduating high school?
Do you have a job? If so, how many hours a week do you work?
* Do you have career/college plans for after high school? If yes, what are they?
* Are you interested in meeting with your mentor during school hours or outside of school hours?
Is there anything preventing you from attending school?