Mentee Application

Youth's Full Name:

Preferred Name (Nickname):

Pronouns

She, her, hersHe, him, hisThey, Theirs

Gender

MaleFemaleNon binary

Ethnicity

CaucasianAmerican IndianAfrican AmericanLatino/ HispanicNative HawaiianPacific IslanderAsian

Age:

Youth Phone(s)

Email

Are you the mentee, parent/guardian, or a community partner referring?

Parent or Guardian #1 Name:

Relationship:

Full Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Parent/Guardian Phone:

Parent/Guardian Email:

Parent/Guardian #2 Name:

Text

Full Address:

Parent/Guardian Phone:

How did you hear of Rogue Valley Mentoring

Parent/Guardian/Agency: Has the child/youth asked/agreed to have a mentor?

If you are a community partner, please share who you are. If not, you may ignore this.

Mentee: Are you able to make a 1-year commitment to your mentoring relationship?

Mentee: Do you know of any upcoming change in our life that may impact your involvement with Rogue Valley Mentoring?

If yes to the above question, please explain:

Why do you wanted to be mentored through Rogue Valley Mentoring?

What are some values and beliefs that are important to you?

Preferred activity setting:

indooroutdooractiveleisure

Please list your skills, hobbies, interest, languages, etc.

Are you in therapy currently and if so, has there been a diagnosis of any kind determined regarding your health?

What do you hope to get out of having a mentor?

Is there anything else that you would like us or your mentor to know about you?

Agreement

By checking 'yes' you agree that all of the above information is correct. This will act as a digital signature confirming this.Yes