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Mentorship Program Application

Thank you for taking interest in our mentorship program! Our goal is to provide effective mentorship for your child. The information provided on your child's application will help us create experiences that are tailored to his/her specific needs.

Student Information
Gender
Legal Guardian(s)
Who does you child live with?
Are both parents involved in your child's life?

How many other minors live in the home with your child?

Is your child involved in any teams or clubs?

How social is your child?

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Loner                               Very Outgoing

How social is your child?

How well does your child follow directions?

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Barely                                  Very Well

How well does your child follow directions?

How trustworthy is your child?

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Not at all                        Very Trustworthy

How trustworthy is your child?
Does your child have issues dealing with anger?
Does your child have a history of running away?
Does your child have a history of self harm?
Has your child ever attempted suicide?
Does your child have a mental health diagnosis?
Has you child been prescribed psychiatric medication?
Does your child currently receive counseling services?
Is your child on probation?
Does your child have a criminal history?
Is your child known to steal?
Does your child smoke, drink or use illegal substances?
Is your child gang affiliated?

By my signature below, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge.

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