Community Youth Advance · Community Youth Advance New Mentee Enrollment Form

Mentee's Background

Please select the mentoring program you are seeking to enroll your child

*

Mentoring To Manhood

Lily Sisterhood

Mentee's Name

*

First Name

Last Name

Mentee's Date of Birth

*

(mm/dd/yyyy)

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Mentee's Email

Verify Email

Mentee's Phone Number

The mentee will be added to the Group Chat monitored by the Mentorship Directors. Weekly activities will be shared within the group chat with the mentees.

Mentee’s Ethnicity

*

Black/African-American

Hispanic/Latino

Native-American

White

Other

Prefer not to answer

Please specify if other

*

Mentee's Birthplace

*

City, State, Country

Parent/Guardian Background

Parent/ Guardian's Full Name

*

Prefix

First Name

Last Name

Suffix

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Email Address

*

Verify Email

*

Primary Phone

*

Cell Phone

Employer

*

Occupation

*

Work Phone

In the case of an emergency can you be reached at work?

*

Yes

No

Who has legal custody of the child?

*

Mother

Father

Both

Other

Parent’s Marital Status

*

Single

Married

Divorced

Widowed

Separated

Prefer not to answer

Spouse's Full Name

*

Annual Household Income

*

This information used for statistical purposes and used for grant proposals.

Below $25,000

$26,000-50,000

$51,000-75,000

$76,000-100,000

Above $100,000

Have you or your child ever received help from a social service agency (eg.Family and Child Services)?

*

Please specify agency

*

How many individuals currently live in your household?

*

Does your household currently receive public assistance?

*

Emergency Contact

Emergency Contact’s Name

*

Prefix

First Name

Last Name

Suffix

Primary Phone Number

*

Mentee's School Information

What School does the prospective mentee attend?

*

Mentee’s current grade level (i.e. 5th grade, 6th grade)

*

Mentee’s most recent GPA

*

Mentee’s anticipated high school graduation year

*

i.e. 2023

Is mentee involved in any extracurricular activities (eg. Sports, Student-Government Association)?

*

Is mentee eligible and receive Free and Reduced Meals (FARM)?

*

Does mentee have an Individualized Educational Program (IEP)?

*

Mentee's Health

Does mentee have any allergies?

*

Please provide a list of the mentee's allergies

*

Does mentee have any health challenges?

*

Please specify all health challenges

*

Is mentee currently taking medication?

*

Please list all medications. Please put N/A if does not apply

*

Please specify what the medication is used for.

*

Has your child ever been has interactions or challenges with...(check all that apply)

*

Police

School

Juvenile Authorities

Court

Neighbors

Friends

Other:

Not Applicable

Please explain your answer

*

Has mentee ever received counseling, therapy, psychiatric treatment, or drug/alcohol abuse treatment?

*

Please specify including dates

*

If yes, please describe including dates.

Mentee’s Primary Care Physician

*

First Name

Last Name

Physician’s Contact Number

*

Does mentee have any physical or mental disabilities

*

Please specify

*

Does mentee have need any special accommodations?

*

Please specify

*

Family information

Please list all the children currently living in your home.

*

Name, Sex, Age, Relationship to you

Please list all other adults currently living in your home, such as grandparents, other adult relatives, boarders, etc.

*

Name, Sex, Age, Relationship to you

General Information

How did you hear about our mentoring programs?

*

Newspaper

Website

Advertisment

Friend

Word of Mouth

Other

How were you referred to Community Youth Advance?

How does your child feel about bring matched with a mentor?

*

Do you have any preferences about the race or religion for the prospective mentor assigned to mentee? If so, please specify.

*

Upon acceptance into the program, are there any special skills or resources you posses that may benefit the program?

*

Word Processing

IT/Web Development & Coding

Fundraising

Public Speaking

Marketing

Financial Management

Human Resources

Other:

Please specify

*

Digital Signature

I verify that the information I am submitting is accurate and truthful to the best of my knowledge.

*

Please type your first and last name to submit your digital signature

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 or 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 organizational 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.

*Students will only be identified by his/her first name unless the reference to the student is in a manner necessary to use his/her full name.

Media Release

*

Agree

Disagree

Nondiscrimination Policy

Community Youth Advance 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.