Mentee Application Form

If you are interested in having a mentor or you are interested in your child having a mentor, please fill out the following form. Youth's First Name Youth's Last Name Birth Date Age Gender Name of School Grade Primary Residence Address Parent/Guardian Email Home Phone Work Phone Cell Phone Parent / Guardian 1 Name Relationship to Youth (Mother, Father, Other: Please Specify) Street Address City Province Postal Code Parent / Guardian 2 Name Relationship to Youth (Mother, Father, Other: Please Specify) Street Address City Province Postal Code Emergency Contact Name Emergency Contact Phone Number Allergies/Medications Saskatchewan Health Card Number

Please answer all of the following questions as completely as possible. These answers will assist in the matching process.

Why do you/your child want a mentor? What type of person would you like to be matched with? Briefly describe your expectations of the mentoring program: One of the program requirements is to communicate with the Program Administrator or Executive Director about your relationships with you and your mentor. Are you okay doing that? Are you/your child able to meet with a mentor a minimum of 2 hours per week? Please explain any scheduling issues you may have. What types of activities would you like to do with a mentor? What are your interests or hobbies? Please describe your/your child’s friendships: Are you/your child currently having problems either at home or at school? If yes, please explain. Have you/your child experienced any traumatic events (ex: death in family, abuse, divorce)? If yes, please explain. Can you provide any additional background information that may be helpful in matching you/your son/daughter with an appropriate mentor? (Anything that we should be aware 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? Is there anything else the SCCYI should be aware of before we move forward with matching you/your child with a mentor?

Please read carefully before submitting:

Thank you for your interest in having a mentor. All information provided in this application is confidential and will only be used as a means to provide a successful mentoring match.

1. Understand that at any time I have questions or concerns about my child’s mentor, I am able to talk to the Program Administrator.
2. Acknowledge that this consent form will be filed at the SCCYI: The Center.
3. Understand that my child will be contacted by the Program Administrator to supervise and monitor the relationship with their mentor.
4. Understand that my child cannot have contact with their mentor outside of the scheduled sessions and planning of sessions.
5. Agree to inform the Program Administrator if I choose to withdraw my child from the program.
6. Release the Swift Current Community Youth Initiative: The Center (including all partners) and their employees, directors, and volunteers from any cause or action or claim for damages arising form my child’s association with the Mentoring Program, or with the Swift Current Community Youth Initiative in its entirety.
7. Consent to my child being transported to and from activities and sessions by the mentor.

By continuing, I agree that all of the above information is true and agree to have my child participate in the SCCYI Mentoring Program.