Young Women Empowered · 2023-2024 Black Girls Matter Mentorship Program

2024 Black Girls Matter Mentorship Program

About the Program: This program was created by Black folks, for Black folks in order to facilitate community and connection. Please visit Y-WE's website for more info, including dates, times, and location. We are excited to open up spots in this program for the remainder of this year's program!

Schedule: monthly on Tuesdays now until May, 4:30-7:30PM, and 1 monthly outing for mentors and mentees

If you have any needs or questions, contact Lennae at programcoordinator@y-we.org.

Youth Information

This form is for young women*, ages 13-18, who wish to enroll in Y-WE Programs. Some sections must be filled out by a parent/guardian. Please look over the application below and prepare to complete and submit it in one session. You WILL NOT be able to save the form mid-way through. Upon completion of this application, you will be contacted by a Y-WE staff member to set-up an interview.

Y-WE Inclusion Policy

*Y-WE welcomes people who identify as a girl/woman, nonbinary, trans, and gender expansive

Name

First Name

Last Name

Preferred first name (if different)

What are your gender pronouns? (optional)

she/her, they/them, he/him, etc.

Birthdate

(mm/dd/yyyy)

Verify Email

May we text you at this number?

Yes

Home Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

What grade are you in this year? (2023-2024 school year)

If you are in school, what school do you attend? (2023-2024 school year)

Do you have any dietary restrictions or food allergies? (for example: vegetarian, halal, allergic to peanuts, etc).

Are there any accommodations you need to make this program accessible and comfortable? (physical space needs, technology support, environmental sensitivities, etc)

Y-WE is dedicated to creating inclusive spaces and programs for all, including people with disabilities and specific accommodation needs.

Do you have any safety or medical concerns which will affect your ability to participate in specific activities during our programs?

Youth Interests Information

Your answers to these questions help us to get to know you better and understand what inspired you to apply to Y-WE. We shape our programs around the passions and goals of the youth who participate, so your answers to these questions really matter to us!

Will this be your first Y-WE event/activity?

How did you hear about Y-WE? (select any/all that apply)

Been in Y-WE programs before

Friend

Teacher or other school staff

Mentor

Parent/Caregiver

Social media/fliers/promotional ads

Other

If you selected 'other' please describe (optional):

What do you hope to gain from participating in this program? What are some of your personal goals?

Is there anything else you would like us to know about your family, your schedule, or your commitment to this program?

I understand the commitment I am making to Y-WE

Since we have limited space in all our programs, and we want to make sure you get the most out of your Y-WE experience, we require a commitment from you to participate in all activities related to the program you are signing up for. If you miss our events regularly, without pre-approval from the program director, we may ask you to leave the program and offer your spot to someone else who can fully take advantage of the opportunity.

Yes, I understand the commitment I am making to Y-WE

Please upload a picture of yourself that you like

Youth Demographic Information

Y-WE collects this data to better understand who we serve, and to improve and obtain support for our programs. Your answers are confidential and will not be shared outside of Y-WE except as part of anonymous percentages. All questions have a 'prefer not to answer' option and we encourage everyone to fill this section out in whatever way feels the most comfortable!

Do you identify as Black?

Please describe your ethnicity or cultural heritage in your own words:

OPTIONAL: If you selected 'Other' please describe:

Do you identify as LGBTQIA+?

OPTIONAL: If you selected 'Other' please describe:

Place of Origin

Your answers are confidential! We do not ask for or keep any record of immigration status.

Primary Household Type (where you live all or most of the time)

OPTIONAL: If you selected 'Other' please describe:

Are you eligible for free or reduced school lunch?

Parent/Caregiver Info

Please fill this section out completely so that we can contact you about upcoming events and notify you if any emergency situation were to arise while this young person is at our program.

Parent/Caregiver Name

First Name

Last Name

Parent/Caregiver(s) Phone Number

Alternate Phone Number

Parent/Caregiver(s) Email Address

Verify Email

Alternate Email Address

Verify Email

Do you live at the same address as your young person?

Parent/Caregiver(s) Primary Address (if different from youth's home address)

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Please tell us a bit about why you are encouraging this young person to sign up for this program, and if there's anything you'd like us to know about them.

I understand the commitment I am making to my young person and to Y-WE :

Yes

Full width Y-WE must have Hold Harmless and Medical forms for each participant before the program begins, signed by a parent/guardian. Youth 18+ can fill out these forms on their own behalf. These forms will be sent to you to fill out before the program

I understand

2024 Black Girls Matter Mentorship Program

About the Program: This program was created by Black folks, for Black folks in order to facilitate community and connection. Please visit Y-WE's website for more info, including dates, times, and location. We are excited to open up spots in this program for the remainder of this year's program!

Schedule: monthly on Tuesdays now until May, 4:30-7:30PM, and 1 monthly outing for mentors and mentees

If you have any needs or questions, contact Lennae at programcoordinator@y-we.org.

Youth Information

Y-WE Inclusion Policy

Youth Information

Youth Interests Information

Youth Demographic Information

Parent/Caregiver Info

Needs Support Check-In