S.T.Y.L.E. Mentee Application To Be Completed by the Parent/Guardian Application Questions: Please answer all of the following questions as completely as possible. Question Title * 1. Today's Date: Date / Time Date Question Title * 2. Mentee's Name: Question Title * 3. Parent/Guardian Name: Question Title * 4. Relationship to Mentee: Mother Father Other (please specify) Question Title * 5. Household Contact Information: Address Address 2 City/Town State/Province ZIP/Postal Code Parent/Guardian's Email Address Phone Number Question Title * 6. Mentee's Date of Birth Date Date Question Title * 7. Mentee's Age Question Title * 8. Mentee's Ethnicity: African American Asian Hispanic White Other (please specify) Question Title * 9. Name of School Question Title * 10. Grade Level 5th 6th 7th 8th 9th 10th 11th 12th Question Title * 11. Emergency Contact's Name Question Title * 12. Emergency Contact's Phone Number Question Title * 13. Please list all members of your household Name Sex (Female/Male) Age Relationship to Applicant Question Title * 14. Why would you like for your child to participate in a mentoring program? Question Title * 15. Briefly describe your expectations for the S.T.Y.L.E. Mentoring Program. Question Title * 16. Is your child available to meet with a mentor eight hours per month for a minimum of one year? Please explain any particular scheduling issues. Question Title * 17. Is your child willing to attend an initial mentee training session and training session(s) per year after being matched? Yes No Question Title * 18. Describe your child’s school performance including grades, homework, attendance, behaviors, etc… Question Title * 19. Does your child have friends? Please describe her friendships. Question Title * 20. Is your child currently having any problems either at home or school? Yes No Question Title * 21. Has your child experienced any traumatic events (i.e., death in the family, abuse, divorce)? If yes, please provide details. Question Title * 22. Can you provide any additional background information that may be helpful to S.T.Y.L.E. Mentoring Program in matching your child with an appropriate mentor? Question Title * 23. Medical History: Name of Primary Care Physician: Question Title * 24. Address: Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 25. Medical Provider Information: Provider's Name: Policy Number: Group Number: Phone Number: Question Title * 26. Does your child have any physical problems or limitations? If yes, please describe. Question Title * 27. Is your child currently receiving treatment for any medical issues? If yes, please describe. Question Title * 28. Is she currently on any type of medication? If so, please list below. Medication Medication Medication Medication Medication Medication Question Title * 29. Does your child have any known allergies or adverse reactions to medications? If yes, please describe them below and adverse reactions. Allergy Allergy Allergy Allergy Allergy Allergy Question Title * 30. Does your child have any emotional issues or problems right now? If yes, please describe. Question Title * 31. Is your child currently seeing a counselor or therapist? Yes No If yes, please provide the therapist's name, agency/organization name, and phone number. Question Title * 32. Please read this carefully before signing S.T.Y.L.E. Mentoring Program appreciates you and your child’s interest in her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their child to participate in the S.T.Y.L.E. Mentoring Program. After receiving this completed application from you, we will evaluate the information and send you a letter letting you know if your child has been accepted into the mentoring program. Much of the information you supply in this application packet will be used to match your child with an appropriate mentor. Therefore, the mentoring staff may, at times, need to access and share this information with prospective mentors and other parties when it is in the best interest of the match. However, we do not reveal names until there is an initial interest from the mentee, parent/guardian, and mentor based first upon anonymous information provided about each other. Please initial each of the following I give my informed consent and permission for my child to participate in the S.T.Y.L.E. 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 her mentor and/or S.T.Y.L.E. staff or representatives while participating in the S.T.Y.L.E. Mentoring Program and that such transportation is voluntary and at her own risk. I release the S.T.Y.L.E organization and S.T.Y.L.E Mentoring Program of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from her participation in the program, including but not limited to transportation, and hold harmless any S.T.Y.L.E. 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 S.T.Y.L.E. 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. Question Title * 33. I understand I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of my application being processed: ▪ Contact and Information Release Form ▪ Interest Survey Form By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions. Done