Mentee Application

Thank you for your interest, please fill out this application with your child to the best of your ability. Don't hesitate to call and ask questions.

Youth Services Mentor Program

509-962-2737
 

* Required field
Basic Information
* First Name
Middle Name
* Last Name
Date of Birth
Contact Information
Mobile Phone
Phone
Email
Custom ID
Basic
T-Shirt Size
Demographic Information
* Gender
Primary Religion
Sexual Orientation
Ethnicity
* Other Ethnicity
Primary Language
Other Primary Language
Secondary Language
Other Secondary Language
Transportation
Public Transit Available
Medical Information
Medical Conditions
Medical Conditions Allergies
Medical Conditions Others
Additional Information
Challenges
Types of Challenges
Challenges Other
Challenges Behavior Other
Description of Challenge
Mentee From Home With a History of
Special Populations
Counseling Information
Counseling Start Date
Counseling End Date
Counseling
Address Information
Address 1
Address 2
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
Family Structure
* Other Family Structure
Career Focused Interests
Career Focused Interests Other
Interests
Interests Other
Photo
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Referral Information
Referral Source
* Other Referral Source
Referral Comments
Referral Date
Reason for Referral
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 Does the Mentee Attend?
Electronic Signature
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This electronic signature verifies you are interested in your child getting a mentor, an actual signature is needed to complete the application process. We will gather this when we meet you and your child in person.