Mentee Application

Please fill out the application as completely as you can. Feel free to have an adult you trust help you. 

* Required field
Basic Information
* First Name
* Last Name
Date of Birth
Contact Information
Mobile Phone
Phone
Email
Demographic Information
* Gender
Sexual Orientation
Ethnicity
* Other Ethnicity
Primary Language
Other Primary Language
Secondary Language
Other Secondary Language
Address Information
Address 1
City
State
Zip Code
Country
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
* Do you live in a New York Housing Authority Building?
* What grade are you in?
* What School do you attend?
* Are you employed? What kind of work do you do?
* Does your parent/guardian need an interpreter?
* Are you available on hour a week for a year?
* Do you think you will have any scheduling conflicts?
* What are your interests or skills? What do you like to do in your free time?
* What are you hoping to gain from having a mentor? Please explain
* Please name 3 leaders you look up to and why?
* Please tell us about your overall health? Please include any special needs that you want us to know about.
* Have you ever had a mentor before? Please explain.
* Please let us know about any challenges or problems at school?
* Please let us know about any problems or challenges you are having at home?
* Have you been through any traumatic events (death of a loved one, abuse, witnessed violence, divorce)? Please explain.
* Have you had contact with the police at school? At home? Or are you involved in the juvenile justice system?
* Have you been involved in the foster care system? If current and you wish to share this information, please provide names of relevant agencies and case workers.
* Is there any additional information that may help us match you with a mentor?