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Community Youth Advance Mentee Form
Mentee's Background
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First Name
Last Name
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(mm/dd/yyyy)
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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City, State, Country
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Parent/Guardian Background
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Prefix
First Name
Last Name
Suffix
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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If Not Applicable, Write N/A
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In case of Emergency or Urgent Matter
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Statistical information for grant proposal.
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Emergency Contact
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Prefix
First Name
Last Name
Suffix
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Absent Parent Information
If Applicable

First Name
Last Name

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country



Mentee's School Information
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Estimated High School Graduation Year
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i.e. SchoolMax, AACPS, DCPS, Veracross


Mentee's Health
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check all that apply. If none, write N/A in blank box

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First Name
Last Name
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Family information
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Name, Sex, Age, Relationship to you
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Name, Sex, Age, Relationship to you
General Information
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$


(mm/dd/yyyy)
Digital Signature
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Media Release

Media Release - Throughout the school year Community Youth Advance will conduct activities that may be publicized through local or national news media. These activities may include interview sessions with news reporters; photographs of individual students or groups of students for newspapers;  Social Media (i.e. Facebook and Instagram) various publications including newsletters, calendars, and brochures; the use of student photos on the Community Youth Advance web site; and videotaping for local and national television news programs, cable programming, and organizationa promotional videos.

I/we grant permission for my/our child’s name, voice, and photographic likeness to be used by Community Youth Advance personnel, or reporters, journalists, or photographers employed by news media.

Nondiscrimination Policy
Mentoring to Manhood does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, height, weight, physical or mental ability.