S.T.Y.L.E. Mentee Intake Form

To Be Completed by the Parent/Guardian

Application Questions: Please answer all of the following questions as completely as possible.

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1. Today's Date:

Date / Time

Date

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2. Mentee's Name:

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3. Parent/Guardian Name:

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4. Relationship to Mentee:

Mother

Father

Other (please specify)

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5. Household Contact Information:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Parent/Guardian's Email Address

Phone Number

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6. Mentee's Date of Birth

Date

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7. Mentee's Age

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8. Mentee's Ethnicity:

African American

Asian

Hispanic

White

Other (please specify)

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9. Name of School

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10. Grade Level

5th

6th

7th

8th

9th

10th

11th

12th

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11. Emergency Contact's Name

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12. Emergency Contact's Phone Number

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13. Please list all members of your household

Name

Sex (Female/Male)

Age

Relationship to Applicant

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14. Medical History: Name of Primary Care Physician:

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15. Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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16. Is your child currently on any type of medication? If so, please list below.

Medication

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17. Does your child have any known allergies or adverse reactions to medications? If yes, please describe them below and adverse reactions.

Allergy

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18. What is the mentee's shirt size?

Small

Medium

Large

X-Large

2XL

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19. 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 intake form 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.

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.

(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.

S.T.Y.L.E. Mentee Intake Form

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* 1. Today's Date:

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* 2. Mentee's Name:

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* 3. Parent/Guardian Name:

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* 4. Relationship to Mentee:

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* 5. Household Contact Information:

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* 6. Mentee's Date of Birth

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* 7. Mentee's Age

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* 8. Mentee's Ethnicity:

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* 9. Name of School

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* 10. Grade Level

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* 11. Emergency Contact's Name

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* 12. Emergency Contact's Phone Number

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* 13. Please list all members of your household

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* 14. Medical History: Name of Primary Care Physician:

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* 15. Address:

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* 16. Is your child currently on any type of medication? If so, please list below.

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* 17. Does your child have any known allergies or adverse reactions to medications? If yes, please describe them below and adverse reactions.

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* 18. What is the mentee's shirt size?

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* 20. By signing below, I attest to the truthfulness of all information listed on this intake and agree to all the above terms and conditions.

1. Today's Date:

2. Mentee's Name:

3. Parent/Guardian Name:

4. Relationship to Mentee:

5. Household Contact Information:

6. Mentee's Date of Birth

7. Mentee's Age

8. Mentee's Ethnicity:

9. Name of School

10. Grade Level

11. Emergency Contact's Name

12. Emergency Contact's Phone Number

13. Please list all members of your household

14. Medical History: Name of Primary Care Physician:

15. Address:

16. Is your child currently on any type of medication? If so, please list below.

17. Does your child have any known allergies or adverse reactions to medications? If yes, please describe them below and adverse reactions.

18. What is the mentee's shirt size?

20. By signing below, I attest to the truthfulness of all information listed on this intake and agree to all the above terms and conditions.