AFGM Mentee Application

AFGM Mentee Application

* Mentee Date of Birth

* Mentee Name

* Mentee Graduation Year from High School

* Parent/Guardian Name

* Date of Application

* Parent/Guardian Email address

* Which location are you seeking a mentor?

Northern Virginia (Includes Fairfax, Prince William, Stafford and Fauquier Counties)

DMV (Includes cities within and immediately surrounding the Beltway)

Hampton Roads (Includes Chesapeake, Virginia Beach, Norfolk etc.)

Atlanta Metro Area

* We offer two types of mentoring. Please select the type you are interested in.

One on One Mentoring

Virtual Mentoring

* Relationship to Mentee

Mother

Father

Other

* Primary Address

* County Of Residence

* Parent/Guardian Cell Phone Number

Parent/Guardian Work Number

* Parent/Guradian DOB

Mentee Cell Phone Number

* Name of school and current grade

* Please list all members of your household.

* Name of Primary Care Physician

* Phone Number of Primary Care Physician

* Do you have medical insurance?

Yes

No

* If yes, list the medical insurance provider and policy number.

* Does your child have any physical problems or limitations?

Yes

No

If yes, to the previous question please explain.

* Is your child receiving treatment for any medical issues?

Yes

No

If yes, to the previous question please explain.

* Is your child currently taking any type of medication?

If yes, to the previous question please explain.

Yes

No

* Does your child have any known allergies or adverse reactions to medication?

Yes

No

If yes, to the previous question please explain.

* Does your child have any mental or emotional issues?

Yes

No

If yes, to the previous question please explain.

Yes

No

* Is your child currently seeing a counselor or therapist?

Yes

No

If yes, to the previous question please explain.

* I give my informed consent and permission for my child to participate in A Few Good MENtors, Inc., mentoring program and it's activities.

Yes

No

PLEASE READ THIS CAREFULLY BEFORE SIGNING. We appreciate you and your child's interest in becoming a mentee. This application is intended as a means of gaining consent of the parent(s)/guardian(s) to allow their child to participate in A Few Good MENtors, Inc. (AFGM) Mentoring Program. The information supplied in this application will be used to match your child with an appropriate mentor. Therefore, it may be anonymously shared with their mentors in the program to determine the best mentor/mentee match. (NOTE - Mentee names are not revealed to a prospective mentor until there is an initial interest from the mentee, parent(s)/guardian(s) and mentor, based upon anonymous information provided about each other). After receipt of the completed application, AFGM will evaluate the information and contact you if a mentor is available at such time to assist your child.

* 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.

Yes

No

* I hereby acknowledge that my child may be transported by his mentor or another AFGM mentor while participating in the mentoring program, and that such transportation is voluntary and at his own risk.

Yes

No

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

APPLICANT QUESTIONS - Please answer the following questions as completely as possible. The answers will aid in matching a mentor to the mentee.

* Briefly describe your expectations of the mentoring program?

* Is your child able to meet with a mentor a minimum of one hour per week?

Yes

No

Other

* Please explain any particular scheduling issues that may prevent weekly communication.

* Describe your child's school/work performance including grades, attendance, behavior, etc.

* Does your child have friends?

Please describe his/her friendships (positive influence, follower, etc.)

* Is your child currently having problems at home, school or work? If yes, please provide details.

* Has your child experienced any traumatic events? if yes, please provide details.

Please describe situations such as death in the family, abuse and divorce.

* Can you provide any additional background information that may be helpful in matching your son 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 at this time?

* Do you release A Few Good MENtors, Inc., of all liability of injury, death, or damages to you, your child, family, estate, heirs, or assignees that may result from his participation in the program, including but not limited to transportation, and hold harmless any mentor, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

Yes

No

* I understand that I must submit a fully completed application for evaluation (any incomplete will result in a processing delay).

Yes

No

* By signing or printing your name below, you attest to the truthfulness of all information listed on this application and agree to all the terms and conditions.

Agree

Disagree

* Parent or Guardian please print or sign below

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