Apply to Become a J-man (Mentee)

Mentee Application

First Name

Last Name

Date of Birth

Current School

Grade

Race/Ethnicity

Parent or Guardian Name

Relationship to Youth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Preferred Method of Contact

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

Briefly describe your expectations for the Journeymen Mentoring Program:

Is your child available to meet with the group at least three times per month (6 hours total) for a minimum of one year? Please explain any particular scheduling issues.

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

Does your child have friends? Please describe his friendships:

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

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

Is your student eligible for free or reduced-price lunch through their school?

Can you provide any additional background information that may be helpful to Journeymen in matching your son with an appropriate mentor group?

First Name

Last Name

Physician’s Name

Phone/Mobile

Does your Participant have health insurance?

Insurance Company

Phone/Mobile

Policy Number

Expiration Date

Emergency Contact Full Name

Relationship to Mentee

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Does your Participant have any medical / physical conditions that would affect his participation in Journeymen?

Does your Participant have any emotional or psychological concerns that need to be addressed?

Is your Participant currently on any type of medication? If so, please specify:

Does your son have any known allergies or adverse reactions to medications? If yes, please describe them below:

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

Is your son currently seeing a counselor or therapist? If so, please share name and/or agency:

Please read this carefully before signing Journeymen Mentoring Program appreciates you and your child’s interest in becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their son or ward to participate in the Journeymen mentoring program. After receiving this completed application from you, we will evaluate the information and contact you to let you know if your child has been accepted into the mentoring program. Much of the information you supply in this application packet may be used to match your child with an appropriate mentor group. 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 your child.


I give my informed consent and permission for my child to participate in the Journeymen Mentoring Program and its related activities.
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.
I acknowledge that my child may be transported by a mentor and/or Journeymen staff or representatives while participating in the Journeymen program, and that such transportation is voluntary and at his own risk.
I release the Journeymen Mentoring Program of all liability of injury, illness, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his participation in the program and hold harmless any Journeymen mentor, program staff, or other representatives, both collectively and individually, of any injury or illness, physical or emotional.
I certify that the information provided in the medical history form is a complete and accurate statement of the physical and psychological factors that may affect my Participant’s involvement in Journeymen. I agree to notify Journeymen should there be any changes in my Participant’s health status. I authorize Journeymen to release this information to medical personnel in an emergency and to contact my Participant’s physician or therapist to clarify any questions related to my Participant’s health. I understand that Journeymen reserves the right to refuse participation to anyone, at their discretion, for medical reasons.
I agree to allow Journeymen to use any photographic image of my child taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials (this is optional but encouraged).

Signature

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Why are you interested in getting involved in Journeymen?

What are some things you like to do with other people?

Who do you most admire and why?

What is one goal you have set for your future?

If you could learn something new what would it be?

What do you hope to get from being involved in Journeymen?

Apply to Become a J-man (Mentee)

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