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*

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 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 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

Name

This field is for validation purposes and should be left unchanged.