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.

Question Title

* 1. Today's Date:

Date / Time

Date

Question Title

* 2. Mentee's Name:

Question Title

* 3. Parent/Guardian Name:

Question Title

* 4. Relationship to Mentee:

Mother

Father

Other (please specify)

Question Title

* 5. Household Contact Information:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Parent/Guardian's Email Address

Phone Number

Question Title

* 6. Mentee's Date of Birth

Date

Question Title

* 7. Mentee's Age

Question Title

* 8. Mentee's Ethnicity:

African American

Asian

Hispanic

White

Other (please specify)

Question Title

* 9. Name of School

Question Title

* 10. Grade Level

5th

6th

7th

8th

9th

10th

11th

12th

Question Title

* 11. Emergency Contact's Name

Question Title

* 12. Emergency Contact's Phone Number

Question Title

* 13. Please list all members of your household

Name

Sex (Female/Male)

Age

Relationship to Applicant

Question Title

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

Question Title

* 15. Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

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

Medication

Question Title

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

Allergy

Question Title

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

Small

Medium

Large

X-Large

2XL

Question Title

* 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

Question Title

* 1. Today's Date:

Question Title

* 2. Mentee's Name:

Question Title

* 3. Parent/Guardian Name:

Question Title

* 4. Relationship to Mentee:

Question Title

* 5. Household Contact Information:

Question Title

* 6. Mentee's Date of Birth

Question Title

* 7. Mentee's Age

Question Title

* 8. Mentee's Ethnicity:

Question Title

* 9. Name of School

Question Title

* 10. Grade Level

Question Title

* 11. Emergency Contact's Name

Question Title

* 12. Emergency Contact's Phone Number

Question Title

* 13. Please list all members of your household

Question Title

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

Question Title

* 15. Address:

Question Title

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

Question Title

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

Question Title

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

Question Title

Question Title

* 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.