EmailMe Form - GGOG Mentee Application

Date *

MM / DD / YYYY

Name *

First Last

Age *

Birthday *

MM / DD / YYYY

Ethnicity *

Grade *

School *

Name of Parent(s)/Guardian(s)

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code

Phone Phone Number

### - ### - ####

Child's Mobile Number

### - ### - ####

Parents Mobile Number

### - ### - ####

Child's Email *

Parents Email Address *

Do you prefer to receive news from Gifted Girls of Grace regarding upcoming events and other important information via email, in the mail, or both? *

Email

Mail

Both

How did you hear about Gifted Girls of Grace? (Choose One) *

Friend

Teacher

After School Program

Table at Lunch

(Please answer all of the following questions as completely as possible.)

1. Why do you/ does your child want to participate in Gifted Girls of Grace? *

2. Briefly describe your expectations of Gifted Girls of Grace. *

3. Is your child available to meet with a mentor at least two hours per month, attend Gifted Girls of Grace monthly meetings, and have contact with her assigned mentor at least once a week for the next three years? Please explain any particular scheduling issues *

4. Describe your child's school performance, including grades, homework, attendance, behavior, etc: *

5. Does your child have friends? Please describe her friendships. *

6. Is your child currently having any behavioral or social problems at home or at school? If so, please provide information that may be helpful for us to know as we work with your child. *

7. Is your child currently dealing with any traumatic events (i.e. death in the family, abuse, divorce)? If yes, please provide details. *

8. Can you provide any additional background information that may be helpful in matching your daughter with an appropriate mentor? *

Mentee Interest Survey

**To be Completed by Youth**
This survey will help us know more about the child and her interests and help us find a good match. All mentees/mentors meet 2 hours per month and have weekly contact.

What are the most convenient times for you to meet with your mentor? Please check all that apply. *

Do you speak any languages other than
English? If so, which languages? *

What are some favorite things you like to do with other people? *

What are your favorite subjects in school? *

If you could learn about a job/career, what would it be? *

What are your favorite subjects to read about? *

What is one goal you have set for the future? *

What person do you most admire and why? *

Describe your ideal Saturday. *

Please check all activities you are interested in: *

List any other areas of special interest:

Mentee Medical History

Name of Primary Care Physician *

Phone *

### - ### - ####

Medical Insurance Provider *

Policy Number

Insurance Provider's Phone Number *

### - ### - ####

Does your daughter have any physical problems or limitations? *

Yes

No

If yes, please describe them:

Is your daughter currently receiving treatment for any medical condition or other challenges *

Yes

No

If yes, please explain

Is she currently on any type of medication? *

Yes

No

If yes, please explain

Does your daughter have any known allergies or adverse reactions to medications? *

Yes

No

If yes, please explain

Are there any other medical challenges or limitations that we need to know about? *

Yes

No

If yes, please explain

Does your daughter have any emotional issues or problems right now? *

Yes

No

If yes, please explain

Is your daughter currently seeing a counselor or therapist? *

Yes

No

If yes, please explain

Counselor/Therapists Name

Phone

### - ### - ####

Parent/Guardian Signature *

Clear

(USE MOUSE OR FINGER OR STYLUS TO SIGN)

Date *

MM / DD / YYYY

We will do our best to match you with a mentor who has similar interests and who we think will be a good role model for the upcoming year. You should meet with your mentor for 2-3 hours a month and try to attend the group activities each month at Hollis Innovation Academy.Your mentor will let you know the times and dates of these fun events. In order to gain the most from the program, you need to make an effort just like the mentor. Please answer the following questions:

1. Will you try your best to meet with your mentor at least once monthly? *

Yes

No

2. Will you try your best to attend every monthly group event? *

Yes

No

Signature *

Clear

(USE MOUSE OR FINGER OR STYLUS TO SIGN)

Date *

MM / DD / YYYY