Mentee Inquiry

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Non-Discrimination Policy

Our participants come to us with a wide range of personal characteristics. We believe that participant eligibility shall be determined without regard to race, ethnicity, religion, national origin, color, gender, marital status, sexual orientation, gender identity, gender expression, citizenship status, veteran status, or disability.

Youth Information

First Name

Last Name

Application Name

Concatenated from First + Last

Preferred Name

Birthdate

Enter as mm/dd/yyyy

What pronouns does the youth use?	How does the youth identify?
Personal Pronouns	Gender

Race/Ethnicity (Check all that apply)

American Indian or Alaska Native	Asian - Chinese
Asian - Filipino	Asian - Indian
Asian - Japanese	Asian - Korean
Asian - Other	Asian - Vietnamese
Black or African American	Hispanic - Cuban
Hispanic - Mexican,Mexican American,Chicano	Hispanic - Other Latinx or Spanish origin
Hispanic - Puerto Rican	Middle Eastern or North African
Pacific Islander - Chamorro	Pacific Islander - Native Hawaiian
Pacific Islander - Other	Pacific Islander - Samoan
White or Caucasian	Other
Prefer not to say

Raza/Etnia (marque todo lo que corresponda)

School

Grade

This is the year the youth will graduate.

School Account ID

12-Grade

Guardian's Relationship to Youth

The parent/guardian is this child's

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Mobile Phone

Personal Email

I prefer to be contacted by

Family Information

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

County

What county do you reside in?

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Contact Information