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
Medical Information
Medical Conditions
Medical Conditions Allergies
Medical Conditions Others
Additional Information
Challenges
Address Information
Address 1
City
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Zip Code
Country
Other Information
Participates in free/reduced lunch
Household Size
Career Focused Interests
Interests
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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
Secondary Emergency Contact
SEC Name
SEC Relationship
SEC Mobile Phone
SEC Home Phone
SEC Work Phone
Secondary Emergency Contact Email
Electronic Signature
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I agree to allow my student to fully participate in the Summer Program.  I understand that there is a cost associated with the participation, which I must pay at the beginning of each week or for the entire summer.  I also understand that my student must participate in all activities.  I also understand that there is a summer college tour, which is a week long activity for which additional costs are incurred..