Mentee Application

* Required field
Basic Information
* First Name
* Last Name
Date of Birth
Contact Information
Mobile Phone
Phone
Custom ID
Basic
T-Shirt Size
Student ID Number
Demographic Information
* Gender
Ethnicity
* Other Ethnicity
Primary Language
Other Primary Language
Transportation
Public Transit Available
Medical Information
Medical Conditions
Medical Conditions Allergies
Medical Conditions Others
Additional Information
Challenges
Address Information
Address 1
City
State
Zip Code
Country
Other Information
Household Size
Family Structure
* Other Family Structure
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
Secondary Emergency Contact
SEC Name
SEC Mobile Phone
SEC Home Phone
Secondary Emergency Contact Email
Electronic Signature
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I agree to participate in the Youthbuild TBAH program.  I represent that the information found in this application is true.  I understand that as a participant I am required to participate in mentoring for a minimum of one year. By my signature I as the student or the parent/guardian if the student is under the age of 18 am stating that I understand the requirements of the Youthbuild TBAH program.