Mentee Application

* Required field
Basic Information
* First 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
Transportation
Public Transit Available
Address Information
Address 1
City
Province, State, or Subnational Division
State
Zip Code
Country
Availability
Before School Availability
AM Block Availability
Lunch
After School Availability
PM Block Availability
Other Information
Participates in free/reduced lunch
Household Size
Career Focused Interests
Interests
Photo
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Referral Information
Referral Source
* Other Referral Source
Emergency Contact Information
Primary Emergency Contact
PEC Name
PEC Relationship
PEC Home Phone
PEC Mobile Phone
PEC Work Phone
Primary Emergency Contact Email
Electronic Signature
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The following application is true and complete to the best of my ability.  I give my consent as a parent for my student to participate in the Mentoring+ program.  I also give my permission for information to be shared with MANY and the U.S. Department of Justice as the funders.