Mentee Application Mentee Form Parents and Guardians: Please fill out this application to request a BCYMP Mentor for your child and/or to apply for small group mentoring. We will then contact you, add your child to our "Pending Mentee" list and begin the process of finding the best match for him or her. Please understand that sometimes it takes several months for the best BCYMP Mentor for your child to apply, finish training and be ready to match. We will update you periodically while your child is waiting, and you are always welcome to call or email us to inquire about the status, too. Our email is: bcymp@bcymentoring.org The more information you give BCYMP on this form, the better able we will be to find a great Mentor. Additionally, we may call you if we need more information or have any questions after submission. Thank you! Child's Information Today's Date * Which BCYMP Mentoring Program(s) are you interested in for your child? You may select more than one. * 1:1 Mentoring Small Group Mentoring (approx. 5 students to 1-2 Mentors) Child's Full Name * Pronoun Mentee's Birthday * Primary Language used at home * Child's Gender * Male Female Other/Non-conforming Child's Grade in School for 2024-25 Year * Child's School * Parenting Adult’s Name and Contact Information Name * Your Relation to Child * Your birthday * Your Employer (if applicable) * Email * Phone * Secondary Phone What is the best way (text, email, call) and time to reach you? Or any other notes we should make regarding your schedule (ex. work nights, please call after Noon). Child's Phone (if different) *We will discuss at Match Meeting if Mentee has personal phone* Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Does the child have another household besides this one? * Yes No Secondary Household Name and Contact Information Parenting Adult’s Name * Email Phone Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal More About Your Child How did you hear about BCYMP? * Please check all the following interests your child has. * Academics Animals and Pets Arts and Crafts Board Games Computer and Video Games Fashion, Makeup and Hair Music and Theater Outdoor Activities Sports and Recreation OtherOther Does your child attend G.A.P., Boys and Girls Club, religious youth groups (if so, which church), sports, utilize a Children's Museum Membership, or other after school activities/services (ex. counseling services)? If so, please list any that may help us get to know the student: Please share why you are enrolling in BCYMP and/or what you hope your child will gain from being a part of BCYMP. Does your child have special health care needs (physical, behavioral, emotional, dietary)? Are there any accommodations that we can make to help your youth participate fully in our program: If needed, please list any reasonable accommodations any parenting adults or siblings may need for any optional family events: Are there other services in Brookings County for your child that you would like BCYMP to try to help you find access to? Would you like to be emailed if we have clothing or food donations available? Would your child be a first generation college student (if they considered continuing their education beyond High School)? Household Information Note: The following 4 questions are optional, and information you provide will be kept confidential. BCYMP relies on Grant Funding to keep programming free. Your answers to these questions are used for data within the grants and will help us measure impact. Thank you in advance for considering answering the following: Does this child or anyone in your household qualify for an assistance program such as the school free or reduced lunch, Medicaid, CHIP, TANF, WIC, SNAP or energy assistance)? Which ones? How many individuals are in your household? What is the current annual income of your household? The parenting adult(s) in this child’s household is (check all that apply) biological parent adoptive parent step-parent relative caregiver grand-parent foster parent OtherOther Last thoughts & Consent Is there anything else you’d like BCYMP to know about your child or household that would help us find a good mentor for him or her? Any additional questions you have for us about BCYMP? (We will do our best to discuss at the Mentee conversation). Please type "yes" to give consent for BCYMP to communicate with your child’s school or other youth-serving organization or entity if it would be helpful in order to find and support the best possible mentoring match? * Please sign indicating you agree with the following and are giving permission to participate. By signing, I give my child permission to participate in the Brookings County Youth Mentoring Program (also known as BCYMP). I give Brookings County Youth Mentoring Program Staff and volunteers to act for me according to their best judgment in any emergency situation. I acknowledge that I am voluntarily assuming the risks involved in participating with/in Brookings County Youth Mentoring Program. On behalf of myself, my heirs, next of kin, successors in interest, assigns, personal representatives, and agents, I hereby (1) waive any claim or cause of action against and release from liability the Brookings County Youth Mentoring Program (BCYMP), its officers, employees, Mentors, volunteers, and agents for any liability for injuries to my person or property resulting from my participation in/with BCYMP. (2) Agree to indemnify and hold harmless the Brookings County Youth Mentoring Program (BCYMP), its officers, employees, Mentors, volunteers, and agents from any claims, causes of action, or liability to any other person arising from my participation with BCYMP; and (3) consent that I am personally liable for any, or all, lost or damaged personal items/equipment. I hereby waive and release Brookings County Youth Mentoring Program, staff, board members, and volunteers from liability for any injuries. I fully acknowledge and understand that this is valid for any time this child participates with the Brookings County Youth Mentoring Program. * signature keyboard Clear Please sign to start the process for getting a BCYMP Mentor for your child. Thank you! * signature keyboard Clear Submit If you are human, leave this field blank.
