Girl Tyme Mentee Application

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Please complete application. If you have any questions or concerns, please email GirlTymeMentoring@Gmail.Com

Email *

Name *

First and last name

Address *

Phone number *

Date Of Birth *

YYYY

Race *

White

Black or African American

Hispanic

Asian

American Indian

Two or More Races

Attending School *

Grade *

Freshman

Sophomore

Junior

Senior

6th

7th

8th

Current GPA:

Parent/ Guardian *

Parent/ Guardian (Telephone, Address and Email) *

What are your hobbies/ interest? *

What are some of your personal achievements/ talents? *

What do you hope to gain from Girl Tyme? *

How did you hear about the program? *

Are you willing to participate in monthly activities? *

Yes

Maybe

Are you willing to commit to Girl Tyme for a year? *

Yes

Maybe

Please explain why you are interested having a mentor. *

What qualities are you looking for in a mentor?

Emergency Contact: *

Please sign and date. This affirms that all above information is true to the best of your knowledge. *

Parent or Guardian Signature if under 18 *

Girl Tyme Mentoring Program Consent Form

Please check in the boxes provided after reading to show that you understand each provision. Please feel free to ask any questions regarding this form.

I agree to follow all of Girl Tyme Mentoring Program rules and guidelines and understand that any violations will result in a suspension and/or termination of mentee status

I understand that the information about the above listed Mentee will be shared with prospective Mentors to aid in facilitating a suitable successful match.

I hereby release and acquit and forever discharge, Girl Tyme Mentoring Program and their Mentors and Representatives of any claim, demands, damages of any kind, known or unknown, resulting in personal injury, death or property damage arising from any accident or incident while a participant is involved in any Girl Tyme event.

I agree to allow Girl Tyme Mentoring Program to use any photographic image of me taken while participating in the mentoring program. These images may be used in promotions or other related marketing material.

I understand that signing this document that I am agreeing to comply with the above terms.

Required

Please Sign and Date *

Parent/ Guardian Signature if under 18 *

Submit

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