Community Youth Advance · Community Youth Advance Returning Mentee Form

Mentee's Background

Mentee's Name *

First Name

Last Name

Mentee's Birthdate *

(mm/dd/yyyy)

Mentee's Email *

Verify Email *

Mentee's Phone Number *

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

Mentee’s Ethnicity (check all that apply) *

Black/African-American

Hispanic/Latino

Native-American

White

Chinese/Asian

Other(please specify)

Prefer not to answer

Please specify your answer *

Parent/Guardian Background Information

Parent/ Guardian's Full Name *

Prefix

First Name

Last Name

Suffix

Email Address *

Verify Email *

Primary Phone Number *

Emergency Contact Information

Emergency Contact’s Name *

Prefix

First Name

Last Name

Suffix

Primary Phone Number *

Mentee's School Information

What School does the mentee attend? *

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

Mentee’s most recent GPA *

Mentee’s expected high school graduation year *

i.e. 2023

Please confirm if the prospective mentee is involved in any extracurricular activities (eg. Sports, Student-Government Association)? *

Please list all activities *

Is mentee for and receive Free and Reduced Meals (FARM)? *

Does mentee have an Individualized Educational Program (IEP)? *

Mentee's Health

Does mentee have any health challenges? *

Please list all health challenges *

Does mentee have any allergies? *

Please list all of the mentee's allergies *

Is mentee currently taking medication? *

Please list all medications. *

Please specify what the medications are used for *

Has mentee ever been in trouble 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. *

Does mentee have any mental or physical disabilities you wish to share? *

Please specify disabilities *

Will mentee require any special accommodations? *

Please specify accommodations *

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.

Media Release *

Agree

Disagree

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

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

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