Mentee Application

Movement of Youth (MOY) prepares youth to lead and succeed in the 21st Century through mentoring and targeted programming led by college students.

Rising Fifth- through Eleventh-graders with a minimum 2.0 GPA (C Average) are eligible for participation in this program.

Note: Movement of Youth prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived from any public assistance program.

The Movement of Youth program will provide selected students with:

  • Team Mentoring to help with the achievement of long-term goals and aspirations. College students from across the country apply annually to become mentors and friends for students in the Movement of Youth program. These close relationships provide students with access to a student scholar who offers knowledge about how to successfully apply to and excel in college.
  • Fun Saturday Leadership Academy sessions twice a month during the school year. These activities are fun and are built to challenge students in various ways intellectually, physically and socially.
  • In-state and out-of-state College Tours to expose participants to college life.
  • A variety of Summer Enrichment Academies to reinforce knowledge learned at Saturday Academy sessions during the regular school year.
  • Opportunities for international travel via the J.U.S.T. Global Fellowship.
  • Assistance applying for college scholarships, including the Tyreic E. Hemphill Memorial Scholarship.

For more information about the application process, please call (800) 956-3820 or e-mail us at info@movementofyouth.org.

* - Required field
Basic Information
* First Name
* Last Name
Date of Birth
Contact Information
Phone
Email
Demographic Information
* Gender
Ethnicity
* Other Ethnicity
Primary Language
Other Primary Language
Address Information
Address 1
Address 2
City
State
Zip Code
Country
Other Information
Participates in free/reduced lunch
Household Size
Family Structure
* Other Family Structure
Career Focused Interests
Interests
Emergency Contact Information
Primary Emergency Contact
PEC Name
PEC Relationship
PEC Home Phone
PEC Mobile Phone
PEC Work Phone
Primary Emergency Contact Email
Secondary Emergency Contact
SEC Name
SEC Relationship
SEC Mobile Phone
SEC Home Phone
SEC Work Phone
Secondary Emergency Contact Email
Program Questions
* What school do you attend?
* What is your current grade level?
Electronic Signature
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PARENT/STUDENT CONTRACT (Must be signed by Parent/Guardian)

By signing above, the parent/guardian and student agree to participate in Movement of Youth (MOY). 

I, Parent/guardian, authorize MOY to obtain and release information about my child to and from his/her school and school staff (including all district and county school schools, non-district charter and independent schools). I authorize the MOY staff to gather my child's grades, schedules, and test scores (report cards and/or End-of-Grade scores) from district and county schools, non-district charter and independent schools. Furthermore, I permit MOY to speak with the teachers and counselors about my child's progress. I understand this information will be kept confidential and that it is necessary for my child to receive maximum support in the program. I also understand that while all information will be kept confidential, some information will be turned over to an outside evaluator who will use the data to conduct an evaluation of the program.

In addition to the release of information mentioned above, the parent/guardian and student also agree:

  • To work hard to have a good relationship with the mentors;
  • Student will attend all required program activities. In the event that student cannot attend an event, parent/guardian or student will notify the program staff within 48 hours of the absence;
  • Student will commit to at least one phone/email exchange with a mentor from the mentoring team per week
  • Student will abide by the rules and regulations of the program;
  • Parent/guardian or student will communicate with the Mentoring Services Director regarding issues of concern at any time during the program; and
  • Parent/guardian and student will fill out a survey at the end of the year.

Parent/guardian and student understand that if student misses three program activities without notifying the program staff within 48 hours, student may lose the privilege of participating in Movement of Youth.