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Community Youth Advance New Mentee Enrollment Form

Thank you for your interest in enrolling your child in our mentoring program. 

This form should be completed by a parent or guardian 18 years or older for first-time mentees seeking to enroll in CYA. If you are re-enrolling your child into the mentoring program, please fill out our Returning Mentee Enrollment Form, which can also be found on our website,

If you have any questions concerning CYA's mentorship program offerings, please contact We look forward to working with you!


CYA Mentoring Staff

Mentee's Background


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.

City, State, Country

Parent/Guardian Background


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

Emergency Contact

Mentee's School Information

i.e. 2023

Mentee's Health

Family information

Name, Sex, Age, Relationship to you

Name, Sex, Age, Relationship to you

General Information

Digital Signature

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. 

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.