Skip to content
S.T.Y.L.E. Mentee Application
To Be Completed by the Parent/Guardian
Application Questions: Please answer
all
of the following questions as completely as possible.
1.
Today's Date:
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2.
Mentee's Name:
3.
Parent/Guardian Name:
4.
Relationship to Mentee:
Mother
Father
Other (please specify)
5.
Household Contact Information:
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Parent/Guardian's Email Address
Phone Number
6.
Mentee's Date of Birth
Date
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
7.
Mentee's Age
8.
Mentee's Ethnicity:
African American
Asian
Hispanic
White
Other (please specify)
9.
Name of School
10.
Grade Level
5th
6th
7th
8th
9th
10th
11th
12th
11.
Emergency Contact's Name
12.
Emergency Contact's Phone Number
13.
Please list all members of your household
Name
Sex (Female/Male)
Age
Relationship to Applicant
14.
Why would you like for your child to participate in a mentoring program?
15.
Briefly describe your expectations for the S.T.Y.L.E. Mentoring Program.
16.
Is your child available to meet with a mentor eight hours per month for a minimum of one year? Please explain any particular scheduling issues.
17.
Is your child willing to attend an initial mentee training session and training session(s) per year after being matched?
Yes
No
18.
Describe your child’s school performance including grades, homework, attendance, behaviors, etc…
19.
Does your child have friends? Please describe her friendships.
20.
Is your child currently having any problems either at home or school?
Yes
No
21.
Has your child experienced any traumatic events (i.e., death in the family, abuse, divorce)? If yes, please provide details.
22.
Can you provide any additional background information that may be helpful to S.T.Y.L.E. Mentoring Program in matching your child with an appropriate mentor?
23.
Medical History:
Name of Primary Care Physician:
24.
Address:
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
25.
Medical Provider Information:
Provider's Name:
Policy Number:
Group Number:
Phone Number:
26.
Does your child have any physical problems or limitations? If yes, please describe.
27.
Is your child currently receiving treatment for any medical issues? If yes, please describe.
28.
Is she currently on any type of medication? If so, please list below.
Medication
Medication
Medication
Medication
Medication
Medication
29.
Does your child have any known allergies or adverse reactions to medications? If yes, please describe them below and adverse reactions.
Allergy
Allergy
Allergy
Allergy
Allergy
Allergy
30.
Does your child have any emotional issues or problems right now? If yes, please describe.
31.
Is your child currently seeing a counselor or therapist?
Yes
No
If yes, please provide the therapist's name, agency/organization name, and phone number.
32.
Please read this carefully before signing
S.T.Y.L.E. Mentoring Program appreciates 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 child to participate in the S.T.Y.L.E. 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 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 first 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 S.T.Y.L.E. 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 hereby acknowledge that my child will be transported by her mentor and/or S.T.Y.L.E. staff or representatives while participating in the S.T.Y.L.E. Mentoring Program and that such transportation is voluntary and at her own risk.
I release the S.T.Y.L.E organization and S.T.Y.L.E Mentoring Program of all liability of injury, death, or other 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 S.T.Y.L.E. mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.
(optional) I agree to allow S.T.Y.L.E. 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.
33.
I understand I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of my application being processed:
▪ Contact and Information Release Form
▪ Interest Survey Form
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.