YES - Mentee Application Please fill out ALL of the following information. All information is kept in a secure database and is used in the matching process. We need ALL the following information to begin the sign up process for the youth to receive a mentor. Thank You. This section is for information on the YOUTH, fill out all that you know: Please note: all fields with an ✱ are required. ✱ First Name ✱ Last Name ✱ Gender: --None--Female Male Other ✱ Race and Ethnicity: --None--White or Caucasian Black or African American Hispanic or Latino/a or Spanish Origin of any race Asian Native American or Alaska Native Hawaiian Native or Other Pacific Islander Two or More Races Other Middle Eastern Race and Ethnicity Unknown ✱ Birthday: Speak Spanish: Phone Email ✱ School Name: ✱ Grade: --None--8th Freshman Sophomore Junior Senior Graduated GED Not currently enrolled College Student ✱ School District: AISD: In DETAIL please provide youth's interests, hobbies and personality. The more information you give the better match we can make! ✱ Interests and Hobbies: Please provide placement's information (person youth lives with). TCJPD PO's please fill the placement's information where the youth will return to live: ✱ Placement Type:--None--Bio Parent Kinship RTC Detention Center TLP/SIL Independent Apt Shelter Dorm Other Foster Home Homeless Adopted ✱ Placement Name: ✱ Placement Phone: ✱ Placement Email: ✱ Street ✱ City ✱ State/Province ✱ Zip If applicable provide the CPS caseworker's information, we will contact them to let them know about the referral: Case Worker Name: Caseworker Phone Number: Case Worker Email: If it applies, please provide the Attorney Ad Litem’s information: AAL Name: AAL Phone: AAL Email: If applicable, please provide the CASA volunteer’s information CASA Name: CASA Phone: CASA Email: If it applies, please provide the case manager’s information Case Manager Name: Case Manager Phone: Case Manager Email: Please fill out the following information in regards to yourself: ✱ Referrer's Name: ✱ Referrer's Phone: ✱ Referrer's Email: ✱ Referrer's Agency: If you are not brought to a thank you page, the form did NOT submit. Please check that ALL required fields are filled out.
