Mentee Application

General Information

Which location are you registering your student for?

The Village Anderson The Village Noblesville

Which group are you registering your student for?

Boys H.U.T.S Girls H.U.T.S

How did you learn about The Village Indiana?

Parent/Guardian Information

Parent/Guardian Name

Parent/Guardian Email

This address will receive a confirmation email

Parent/Guardian Phone (ex. 555-555-5555)

Phone Type

Mobile Work Home

Would you like to receive text messages from The Village Indiana?

Yes No

What's the best time of day to call to set up an interview for you and the prospective youth?

AM PM No Preference

Address

Can you tell us why your child needs a mentoring program?

In addition to time and financial commitments, our mentoring programs require an openness to build and expand a family support system. Are there any time constraints for you, and/or barriers to the mentee participating in the mentoring program at least 75% of the time?

Do you believe in God or in the concept of a higher power? If so, describe the most useful and empowering aspects of your relationship with God. If not, what reference point do you use?

How would you characterize the family's yearly income?

$0-$20,000 $20,000 - $45,000 $45,000 - $60,000 $60,000 or more

Student Information

Name

Preferred Name

Birth Date

Primary Address

School

Grade Level

6th 7th 8th 9th 10th 11th 12th

Ethnicity

African American Caucasian Hispanic Asian Native Hawaiian/Pacific Islander Native American or Alaskan Native

Preferred Language

English Spanish Other (please list below)

Shirt Size

Has the student been involved with the Juvenile Justice System in the last 12 months

No Yes

Allergies, Special Needs or Other information

Emergency Contact #1

Name

Phone

Phone Type

Mobile Work Home

Relationship to Student

Emergency Contact #2

Name

Phone

Phone Type Mobile Work Home

Relationship to Student

Waivers

I agree to allow the mentoring program to use any photographic image of the mentee taken while participating in program activities. These images may be used in promotions or other related marketing materials for the program, including social media.

Yes No

As a parent/guardian, I give my permission for my child to participate in your organizations' programs. I understand that your organization is not obligated to match my child with a volunteer mentor and that, as part of the enrollment process, I will be asked to provide personal information. If my child is matched with a mentor, I agree to support his/her match and to immediately report any concerns I might have with staff. PLEASE TYPE YOUR NAME BELOW signifying an e-signature.

Mentee Application

Description

Please Fix the Following