Youth Mentee Application

    YOUTH MENTEE APPLICATION

    (To Be Completed by Parent/Guardian)

    Relationship to Youth

    Ethnicity

    Please list all members of your household (incl. Name, Gender, Age, Relationship).

    Application Questions

    Please answer all of the following questions as completely as possible. The answers to these questions will aid us in the matching process.

    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 a minimum of one hour per week? Please explain any particular scheduling issues that you may have.
    Describe your child’s school performance including grades, homework, attendance, behaviors, etc.
    Does your child have friends? Please describe her friendships
    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?
    Is there anyone your child should not have contact with?

    Medical History

    Does your daughter have any physical problems or limitations?

    Is your daughter receiving treatment for any medical issues?

    Is he/she currently taking any type of medications? If yes, please explain
    Does your daughter have any known allergies or adverse reactions to medications? If yes, please explain.
    Does your daughter have any emotional issues right now? If yes, please explain.
    Is your daughter currently seeing a counselor or therapist? If yes, please explain.
    Please agree by checking each of the following:

    I give my informed consent and permission for my child to participate in the iSparkle2 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 her mentor while participating in the mentorship program, and that such transportation is voluntary and at her own risk.

    I release the iSparkle2 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 hereby grant permission for the iSparkle2 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, me 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.

    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, we will evaluate the information and notify you by email 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.

    The cost to participate in the iSparkle2 EmpowHERment mentoring program is free.

    By signing and submitting your name below, I attest to the truthfulness of all information listed on this application and agree to all of the above terms and conditions.

    Parent Name
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