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Mentee Registration Form

Thank you for your interest in our Mentorship program. Please complete the form below to register ages 12-18 for our specialized Mentorship program.

We're excited to have you join our community!

Parent/ Guardian Information

Full Name of Parent/Guardian

Relationship to Mentee

Email

Phone

Address

Mentee Information (Ages 12-18)

Full Name

Date of Birth * required

Gender Identity

Race/Ethnicity (Check all that apply)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Two or More Races

Prefer not to say

Other

School Name

Current Grade Level

Does your child have an IEP or 504 Plan?

Yes

No

Prefer not to say

Allergies/ Medical Conditions/ Behavioral Concerns

Emergency Contact Name and Relationship

Emergency Contact Phone Number

2nd Emergency Contact Name and Relationship

2nd Emergency Contact Phone Number

Interests & Goals

What are your child's interests or hobbies?

What specific areas would you like the Adult Mentor to support? Check all that apply. * Required

Social / Emotional Support

Communication Skills

Leadership Skills

Confidence Building

Discovering their Interests

Career Exploration

Life Skills

Conflict Resolution

Other

What are you hoping they gain from this mentorship?

What are your preferred days for mentorship sessions? Check all that apply. * Required

Monday - Oakhaven Middle

Tuesday - Cunningham CC

Wednesday- Gaston CC

Thursday- Oakhaven Middle

Friday

Saturday

Consent & Agreements

Participation and Program Consent: I hereby give permission for child to participate in the mentorship program offered by Memphis Youth Development Group. I understand that mentors are screened and trained, but are not licensed therapists or educators. I understand that participation is voluntary and that either party may discontinue participation at any time.

Parent / Guardian Initials

Media Release: I GRANT permission for Memphis Youth Development Group to photograph, record, and use images or recordings of my child for promotional, educational, and reporting purposes. *

Agree

Disagree

Parent / Guardian Initials

Transportation: I acknowledge that Memphis Youth Development Group does not provide transportation and is not liable for any transportation-related incidents if I or another guardian is responsible for my child’s travel to/from program activities.

Parent / Guardian Initials

Confidentiality & Mandatory Reporting: I understand that mentors are trained to maintain confidentiality, except in cases where disclosure is required by law (e.g., suspected abuse, danger to self/others). I acknowledge Memphis Youth Development Group complies with mandatory reporting laws.

Parent / Guardian Initials

Liability Waiver: I understand that Memphis Youth Development Group, including its staff, volunteers, and affiliates, are not responsible for any injuries or problems that may happen during my child’s participation in the mentorship program.

Parent / Guardian Initials

By signing below, I confirm that all information provided is accurate to the best of my knowledge. I understand and agree to the terms stated above.

Today's Date * required

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Thank you submitting! A member of our team will reach out to you soon with next steps.

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