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 address is bcymentoring@gmail.com. The more information you give BCYMP on this form, the better able we will be to find a great Mentor, so we may call you if we need more information. 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: Social/Emotional Focus Small Group Mentoring: Academic Focus Child's Full Name * Birthdate * Child's Gender * Male Female Other/Non-conforming Child's Grade in School for 2020-21 Year * Child's School * Parenting Adult’s Name and Contact Information Name * Your Relation to Child * Email * Phone * May BCYMP text you? * Yes No Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal More About Your Child Pleae 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 have special health care needs (physical, behavioral, emotional, dietary)? Does your child attend G.A.P., Boys and Girls Club, or other after school activities? Which ones? Are there other services in Brookings County for your child that you would like BCYMP to try to help you find access to? Household Information Note: The following questions are optional, and information you provide will be kept confidential, and only reported in aggregate for grant proposals and impact assessment. 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 gross monthly 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 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? If you are human, leave this field blank. Submit
