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Mentee Application
Bella Feldman
2020-10-06T12:33:40-07:00
Mentee Application
Who is the person completing this form?
*
Mentee
Parent/Guardian
Community Partner Referring
Community Partner
Community Partner: Please share who you are
*
Community Partner: Has the child/youth asked/agreed to have a mentor?
Yes
No
Mentee
Mentee's Full Name
*
First
Last
Preferred Name (Nickname)
*
Pronouns
*
She, her, hers
He, him, his
They, theirs
Gender
*
Male
Female
Non binary
Ethnicity
*
caucasian
American Indian
African American
Latino/ Hispanic
Native Hawaiian
Pacific Islander
Asian
Age
*
Please enter a number from
1
to
30
.
Mentee's Phone(s)
*
Mentee's Email
*
Is the Mentee able to make a one year commitment to their mentoring relationship?
Yes
No
If the Mentee knows of any upcoming changes in their life that may impact their involvement with Rogue Valley Mentoring, please explain here
Why does the Mentee want to be mentored through Rogue Valley Mentoring?
Mentee Personal Information
What are some values and beliefs that are important to you
Preferred activity setting
indoor
active
Please list skills, hobbies, interest, languages, etc.
Is Mentee in therapy currently and if so, has there been a diagnosis of any kind determined regarding health?
What does Mentee hope to get out of having a mentor?
Is there anything else Mentee would like us or their mentor to know about Mentee?
Parent or Guardian #1
Parent or Guardian #1 Full Name
First
Last
Parent or Guardian #1 relationship to Mentee
Parent or Guardian #1 Full Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent or Guardian #1 Phone
Parent or Guardian #1 Email
Parent or Guardian #1: Has the child/youth asked/agreed to have a mentor?
Yes
No
Parent or Guardian #2
Parent or Guardian #2 Full Name
First
Last
Parent or Guardian #2 relationship to Mentee
Parent or Guardian #2 Full Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent or Guardian #2 Phone
Parent or Guardian #2 Email
Parent or Guardian #2: Has the child/youth asked/agreed to have a mentor?
Yes
No
Agreements and Signature
Additional Comments
Send Mentee Application confirmation email to this email address
*
Agreement
*
By checking 'Yes', I agree that all information provided above is correct. This will act as a digital signature confirming this.
Yes
Signature
*
Please sign the form, using your finger on a touch device, or mouse on computer
Phone
This field is for validation purposes and should be left unchanged.