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Community Youth Advance Returning Mentee Form

This form should be completed by a parent or guardian 18 years or older for returning mentee's seeking to enroll in CYA's 2022-2023 cohort. If you are enrolling your mentee for the first time, please fill out our New Mentee Form which can also be found on our website www.communityyouthadvance.org. If have any questions concerning CYA's mentorship program offerings, please reach out to ahargrove@cya.org. We look forward to working with you!

Best, 

- CYA Mentee Staff

Mentee's Background
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First Name
Last Name
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(mm/dd/yyyy)
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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.
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Parent/Guardian Background Information
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Prefix
First Name
Last Name
Suffix
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Emergency Contact Information
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Prefix
First Name
Last Name
Suffix
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Mentee's School Information
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i.e. 2023
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This information is use to monitor your child's academic responsibilities (i.e. SchoolMax, AACPS, DCPS, MCPS, Veracross)
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Mentee's Health
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General Information
Parent 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 website; 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. 

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CYA’s 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.

Digital Signature
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Please enter your first and last name to submit your digital signature