Mentee Application Continued | Become a Man Without a Man

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

Is your child available to meet with a mentor eight to twelve hours per month and have contact at least once a week for a minimum of one year? Please explain any scheduling issues.

Briefly describe your expectations for the Become a Man Without a Man, Inc. Mentoring Program:

Is your child available to meet with a mentor eight to twelve hours per month and have contact at least once a week for a minimum of one year? Please explain any scheduling issues.

Yes

Is your child willing to attend an initial mentee training session and two training sessions per year after being matched?

Yes

Describe your child’s school performance including grades, homework, attendance, behaviors, etc.:

Does your child have friends?

Yes

Please describe his/her friendships.

Is your child currently having any problems either at home or school?

Has your child experienced any traumatic events (i.e., death in the family, abuse, divorce)? If yes, please provide details.

Please provide any additional background information that may be helpful to Become a Man Without a Man, Inc. in matching your son with an appropriate mentor?

Primary Care Physician

Phone Number*

Medical Insurance Provider

Policy Number

Insurance Phone Number

Does your son have any physical problems or limitations?

Yes

If yes, please explain.

Does your son have any known allergies or adverse reactions to medications? If yes, please describe them below:

Does your son have any emotional issues or problems right now?

Yes

Is your son currently seeing a counselor or therapist?

Yes

Please mark each of the following

I give my informed consent and permission for my child to participate in the Become a Man Without a Man, Inc. Mentoring Program and its related activities.

I agree to have my child follow all mentoring program guidelines and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship.

I hereby acknowledge that my child will be transported by his mentor and/or Become a Man Without a Man, Inc. staff or representatives while participating in the Become a Man Without a Man, Inc. Mentoring Program and that such transportation is voluntary and at his own risk.

I release the Become a Man Without a Man, Inc. Mentoring Program of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his participation in the program, including but not limited to transportation, and hold harmless any Become a Man Without a Man, Inc. mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

(optional) I agree to allow Become a Man Without a Man, Inc.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.

By typing my name below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.*