Participant's Name (Child) *Participant's Name (Child) *Parent/Legal Guardian's Name *Parent/Legal Guardian's Name *Parent Phone Number *Parent Email Address *Address *Date Of Birth *Age *Grade *Ethnicity WhiteHispanicAfrican AmericanAsianSchool Does your child participate in the Free or Reduced Lunch program? YesNoHow many reside in the household? Emergency Contact Emergency Contact's Phone # Why do you/your child want to participate in a mentoring program? Briefly describe your expectations of the mentoring program? Is your child available to meet with a mentor on every 1 st , 2 nd and 3 rd Wednesday of each month? YesNoPlease explain any particular scheduling issues that you may have. Describe your child’s school performance including grades, homework, attendance, behaviors, etc. Is your child currently having problems either at home or at school? If yes, provide details. Has your child experience any traumatic events (i.e. death in the family, abuse, divorce)? If yes, please provide details. Can you provide any additional background information that may be helpful in matching your daughter with an appropriate mentor? (Anything that we should be aware of that could be a trigger for you or your child.) Do you have any religious preferences you would like for us to take into consideration? YesNoIs there anyone your child should not have contact with? Name of Primary Care Physician Primary Care Phone Policy Number Medical Insurance Phone Number Is she currently taking any type of medications YesNoIf yes, please explain Does your daughter have any known allergies or adverse reactions to medications YesNoIf yes, please explain Does your daughter have any emotional issues right now? YesNoIf yes, please explain Is your daughter currently seeing a counselor or therapist? YesNoIf yes, please explain Please read this carefully before signing: We appreciate you and your child’s interest in her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their daughter to participate in the 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 mentoring program. Much of the information that 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 upon anonymous information provided about each other.Please Initial each of the following: I give my informed consent and permission for my child to participate in the Ladies of Leadership Mentoring Program and its related activities. *I agree to have my child follow all of the mentoring program guidelines and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship. *I hereby acknowledge that my child may be transported by his/her mentor while participating in the mentorship program, and that such transportation is voluntary and at her own risk. *I release the Ladies of Leadership Mentoring Program of all liability of injury, death, or damages to me, my child, family, estate, heirs, or assigns that may result from her participation in the program, including but not limited to transportation, and hold harmless any mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined. I understand that I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of this application being processed: *•Signed application • Contact and Information Release Form • Youth Mentee Guidelines/Instructions Form By signing below, I attest to the truthfulness of all information listed on this application and agree to all of the above terms and conditions. *I hereby grant permission for the Ladies of Leadership Mentoring Program to make contact with my child and conduct a personal interview for the purpose of applying to be a mentee. Further, I understand that basic information about my child will be anonymously (without names) shared with a prospective mentor(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my and my child’s identity and other relevant information will be shared with the mentor to the extent it aids in facilitating a successful match. *Date *Are you interested in being a part of L.O.L Mom's Group (Women of Worth)? YesNoNameSubmit
