Mentee Application

How did you hear about us?

Social Media

Email

Word of Mouth

Personal Referral

Mentee First name

Mentee Last name

Parent/ Guardian First Name

Parent/ Guardian Last Name

Email

Phone

Mentee Birthday

Mentee Gender (Please Specify)

Current Location

Charlotte, NC

Las Vegas, NV

Pensacola, FL

Emergency Contact Name

Emergency Contact Phone

Current Grade

Enrolled School/ Educational Institution

Mentee Career or Educational Interests:

Mentee Hobbies and Extracurricular Activities:

What skills, expertise, or knowledge would mentee like to learn from this program?

Does mentee have any particular challenges or obstacles they hope a mentor can help them overcome?

Has mentee been mentored by individuals or groups before?

Yes

No

Is mentee willing to commit to attending Bi-Weekly and sometimes weekly workshops through program duration? Workshops are held on Saturday mornings (times may vary).

Yes

No

Other

Does mentee have a reliable method of transportation?

Yes

No

Other

Mentee Preferred Method of Communication

Do you consent to video calls and the recording of mentorship sessions for program quality, training, and promotional purposes?

Yes, I consent to video recording and understand it may be used for program improvement or promotional materials.

No, I do not consent to video recording.

I understand this is a mentorship program, not a "babysitting" service. My child must follow program rules, actively participate, and engage respectfully with mentors. Failure to do so may result in removal from the program.

I understand that this mentorship program requires my child to be an active participant, follow the rules, and engage respectfully. I acknowledge that failure to meet these expectations may result in my child’s removal from the program.

To complete full enrollment in the mentorship program, please submit a copy of the participants most recent report card or progress report. You may upload it digitally or provide a physical copy in person before the cohort start date.

I give permission for my child to participate in this mentorship program

Parent/Guardian Signature