Lift Career Resource Center Mentee Form
Welcome!
Please complete this form in entirety!
Personal Information
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
*
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Social Security Number
Gender
*
Female
Male
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Ethnicity
*
Caucasian / White
Hispanic / Latino
African American
Asian
Other
Name of school you attend, if you attend school at present.
Student Classification (i.e. Freshman, Sophomore, etc.)
Student Classification (i.e. Freshman, Sophomore, etc.)
Name of emergency contact
Phone number for person we should contact in case of emergency.
Relationship to you? (Example: Parent, guardian, friend)
What day is best for your mentor to contact you? Please indicate if you prefer AM or PM.
Rows
AM
PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunda
Are you available to meet with you mentor or attend training sessions eight hours per month (2 hours per week) and have contact at least once a week with your mentor for the period of one year?
Yes
No
Application Questions
Please answer all of the following questions as completely as possible.
Why do you wish to participate in a mentoring program?
Briefly describe your expectations of Lift Career Resource Center.
Please explain any scheduling issues you might have?
Are you willing to attend an initial mentee training session?
Describe your school performance, including grades, homework, attendance, behaviours.
Are you currently experiencing problems where you live or at school?
Have you recently experienced any traumatic events (i.e. death in the family, etc.) If yes please provide details.
Please provide any additional background information that you feel may be helpful to Lift Career Resource Center in matching you with appropriate mentor.
Submit
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