Mentee Application

Personal Information

Youth's Full Name

This field is required.

Date

This field is required.

Parent/Guardian Name

This field is required.

Guardian Relationship

Mother

Father

Other

This field is required.

If other selected

This field is required.

Street Address

This field is required.

Line 2

This field is required.

City

This field is required.

State

This field is required.

Postal Code

This field is required.

Country

This field is required.

Home Phone

This field is required.

Work Phone

This field is required.

Youth's SSN

This field is required.

Birthdate

This field is required.

Age

This field is required.

If other selected

This field is required.

School

This field is required.

Grade

This field is required.

Emergency Contact Name

This field is required.

Emergency Contact Phone

This field is required.

Household Members

List up to 5 household members.

This field is required.

Application Questions

1. Why do you/your child want to participate in a mentoring program?

Describe your reasons for wanting a mentor.

This field is required.

2. Briefly describe your expectations for the Marc’d For Greatness Youth Mentoring Program:

Detail what you hope to gain from this mentoring experience.

This field is required.

3. Is your child available to meet with a mentor eight hours a month and have contact at least once a week for a minimum of one year?

Please explain any particular scheduling issues.

This field is required.

4. Is your child willing to attend an initial mentee training session and two training sessions per year after being matched?

Yes

This field is required.

5. Describe your child’s school performance including grades, homework, attendance behaviors, etc.

This field is required.

6. Does your child have friends?

Provide details about his/her friendships.

This field is required.

7. Is your child currently having any problems either at home or school?

This field is required.

8. Has your child experienced any traumatic events (i.e., death in the family, abuse, divorce)?

If yes, please provide details.

This field is required.

9. Can you provide any additional background information that may be helpful to assist us in matching your son/daughter with an appropriate mentor?

This field is required.

Medical History

Physician Name

Name of the youth's physician.

This field is required.

Physician Phone

Contact number for the youth's physician.

This field is required.

Insurance Provider

Insurance provider information.

This field is required.

Policy Number

Insurance policy number.

This field is required.

Does your son/daughter have any physical problems or limitations?

Yes

This field is required.

If yes, please describe

Is your son/daughter currently receiving treatment for any medical issues? Is he/she currently on any type of medication?

Yes

This field is required.

If yes, please describe

Does your son/daughter have any known allergies or adverse reactions to medications?

Yes

This field is required.

If yes, please describe

Does your son/daughter have any emotional issues or problems right now?

Yes

This field is required.

If yes, please describe

Is your son or daughter currently seeing a counselor or therapist?

Yes

This field is required.

Therapist name

This field is required.

Please read this carefully before signing:

Marc’d For Greatness Foundation Youth Mentoring Program appreciates you and your child’s interest in his/her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their son/daughter to participate in our youth mentoring program.

After receiving this completed application from you, we will evaluate the information and send you a letter letting you know if your child has been accepted into the youth mentoring program. Much of the information you supply in this application packet will be used to match your child with an appropriate mentor. Therefore, the mentoring staff may, at times, need to access and share this information with prospective mentors and other parties when it is in the best interest of the match. However, we do not reveal names until there is an initial interest from the mentee, parent/guardian,
and mentor based first upon anonymous information provided about each other.

Marc’d For Greatness Foundation Youth Mentoring Program appreciates you and your child’s interest in his/her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their son/daughter to participate in our youth mentoring program.

I give my informed consent and permission for my child to participate in the Marc’d For Greatness Foundation Youth Mentoring Program and its related activities.

This field is required.

I agree to have my child follow all mentoring program guidelines and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship.

This field is required.

I hereby acknowledge that my child will be transported by his/her mentor and/or Marc’d For Greatness Foundation staff or representatives while participating in the Marc’d For Greatness Foundation Youth Mentoring Program, and that such transportation is voluntary and at his/her own risk.

This field is required.

I release the Marc’d For Greatness Foundation Youth Mentoring Program of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any Marc’d For Greatness Foundation mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

This field is required.

I agree to allow Marc’d For Greatness Foundation to use any photographic image of my child taken while participating in the youth mentoring program. These images may be used in promotions or other related marketing materials. (Optional)

I understand I must return this application and any other information requested by Marc’d For Greatness Foundation staff, and that any incomplete information will result in the delay of this application being processed.

This field is required.

By signing below, I attest to the truthfulness of all information listed on this application, consent to my son/daughter participating in the Marc’d For Greatness Foundation Youth Mentoring Program, and agree to all the above terms and conditions.

Parent/Guardian Signature

This field is required.

Date

This field is required.