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Community Youth Advance Mentee Form
Mentee's Background
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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(mm/dd/yyyy)
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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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Emergency Contact
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Prefix
First Name
Last Name
Suffix
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In case of Emergency or Urgent Matter
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If Not Applicable, Write N/A
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Statistical information for grant proposal.
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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
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Estimated High School Graduation Year
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check all that apply. If none, write N/A in blank box

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Mentee's Health
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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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Digital Signature
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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.