Mentee

Application

PROSPECTIVE MENTEE INFORMATION

We appreciate your interest in becoming a mentor. The information in this application will be kept confidential.

Blank Form (#6)

Date

Mentee Information

Mentee's First Name

Mentee's Last Name

Mailing Address

City

State

Zip Code

Mentee's E-Mail

School

Grade

District

Mentee’s Date of Birth

Age

Gender

Male

Female

If other, please specify

List any medical, concerns, mental health conditions or allergies:

What three words best describe you?

List some of your hobbies or interests:

Mentee's Signature

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Date

Parent/ Guardian Contact Information

Parent's First Name

Parent's Last Name

Mailing Address

City

State

Zip Code

Relationship to Mentee (Mother, Dad, etc.)

Best number to reach you at in case of an emergency

Parent’s E-Mail

Parent’s Cell Phone

Parent’s Work Phone

OurGEMS and OurGents are mentoring programs available to students 9 years to 21 years of age.
Research has proven that the mentoring relationship has great benefits to your student’s academic, social
and emotional well-being. All mentors are thoroughly screened and must complete a background check
for your child’s safety. Mentors receive training to lay the foundation for a successful mentoring
relationship as well as clarify roles, boundaries, expectations, and safety issues.

We are required to report any minor (under 18 years of age), who is currently endangered by abuse or
neglect, and to report if children are suspected of being a danger to themselves or others. OurGEMS and
OurGents is not responsible for any accident or loss of property incurred during the mentoring
relationship. OurGEMS and OurGents’ program staff, mentor, or other representatives, both collectively
and individually, are released of any fault or liability of any kind or nature incurred during the mentoring
relationship.

In permitting your child to participate in the OurGEMS and OurGents program, you understand that
OurGEMS and OurGents is authorized to release or exchange any relevant information with its partners
solely for reporting purposes. We request your permission for your child’s participation. Your child’s
participation is completely voluntary.

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

Parent/Guardian Signature

Sign Here

Date