Child/Youth Application 
(To Be Completed by the Parent/Guardian)
Child/Youth between the ages of 10-17 years old.

This application must be completed by the parent or guardian of the perspective child/youth participant. The purpose of this application is to help LEAPs know more about the mentee and her interests. In turn, the information you provide will help LEAPs match the mentee’s interests with a mentor.

Upon completion of this application, please return it to the CEO at P.O. Box 401, Saraland, AL  36571. If you have any questions, please call us at (251) 533-3043. Thank you for granting your child/children permission to participate in LEAPs.

Personal Information
Youth’s Name:	Date Of Birth	Age	Parent/Guardian Name:	Relationship to Youth: 
Mother / Father / Other (specify)	

Youth Social Sec. #:	Gender:	Ethnicity:	

      African American           Asian                Hispanic                White	

Street Address:	Home Phone	Work Phone	Cell Phone	Email	

					

How did you hear about LEAPS?	

	

Name of School	Grade:	Emergency Contact Name: 	Phone Number:  	Email	

					

Please List All Members Of Your Household:
Name	Gender	Age	Relationship To Applicant	

				

				

Application Questions

Please answer all of the following questions as completely as possible. If more space is needed, use an extra sheet of paper or write on the back of this page.

Why Do You And Your Child Want To Participate In A Mentoring Program?

Please Describe Your Family’s Experience With Any Debilitating Illness.(i.e: Cancer, AIDS, Diabetes, Etc). Who Has Been Diagnosed? What Type Disease? What Are The Current Circumstances? (As Applicable)

Briefly Describe Your Expectations For The LEAPs:

Is Your Child Available To Meet With A Mentor Eight Hours Per Month And Have Contact At Least Once A Week For A Minimum Of One Year? Please Explain Any Particular Scheduling Issues.

Is Your Child Willing To Attend An Initial Mentee Training Session And Two In-Service Training Sessions Per Year After Being Matched?

Describe Your Child’s School Performance Including Grades, Homework, Attendance, Behaviors, Etc.:

Does Your Child Have Friends? Please Describe Her Friendships.

Is Your Child Currently Having Any Problems Either At Home Or School?

Has Your Child Experienced Any Traumatic Events (I.E., Death In The Family, Abuse, Divorce)? If Yes, Please Provide Details. (This information is strictly held confidential and will only be supplied to the mentor paired with your child and the selection committee.)

Can You Provide Any Additional Background Information That May Be Helpful To Leaps In matching Your Daughter With An Appropriate Mentor?

Medical History

Name of Primary Care Physician:	Phone No.:	Medical Insurance Provider:	Policy Number:	Phone No.:	

Does your daughter have any physical problems or limitations?

Is your daughter currently receiving treatment for any medical issues?

Is she currently on any type of medication? Is so, please specify.

Does your daughter have any known allergies or adverse reactions to medications? If yes, please describe them below:

Does your daughter have any emotional issues or problems right now?  If so, please describe below.

Is your daughter currently seeing a counselor or therapist?

If so, Therapist’s Name & Phone #:  	
Please Read This Carefully Before Signing:
LEAPs appreciates you and your child’s interest in her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their daughter to participate in the LEAPs program.

Please know that after receiving this completed application from you, we will evaluate the information and send you a letter letting you know if your child has been accepted into the mentoring program. Much of the information you supply in this application packet will be used to match your child with an appropriate mentor. Therefore, the mentoring staff may, at times, need to access and share this information with prospective mentors and other parties when it is in the best interest of the match. However, we do not reveal names until there is an initial interest from the mentee, parent/guardian, and mentor based first upon anonymous information provided about each other.

Please initial each of the following acknowledging you agree:

  ______  I give my informed consent and permission for my child to participate in the LEAPs mentoring program and its related activities.

 	 ______  I agree to have my child follow all mentoring program guidelines and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship.

 ______ I hereby acknowledge that my child will be transported by her mentor and/or LEAPs staff or representatives while participating in the LEAPs mentoring program, and that such transportation is voluntary and at her own risk.

 ______ I release the LEAPs mentoring program of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from her participation in the program, including but not limited to transportation, and hold harmless any LEAPs mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

 	 ______ (optional) I agree to allow LEAPs to use any photographic image of my child taken while participating in the mentoring program. These images may be used in promotions or other related marketing material

______  I understand I must return all of the following items along with this application, and that any incomplete information will result in the delay of my application being processed:
Contact and Information Release Form
Mentee Interest Survey Form 

By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

___________________________________________________                                   ________________
Parent/Guardian Signature                                                                    Date 		
Contact and Information Release
(To Be Completed by the Parent/Guardian)

Youth’s Name:	School:	Date:	

	

______  I hereby grant permission for LEAPs to make contact with my child and conduct a personal  interview for the purposes of applying to be a mentee. LEAPs may also make contact with my child on school premises for the purposes of screening and interviewing as well as ongoing support of her participation in the mentoring program.

______  I authorize LEAPs to obtain any needed information regarding my child from her school’s staff, including academic and behavioral records and conversations with teachers, counselors, and other administrative staff.

______  Further, I understand that basic information about my child will be anonymously (without names) shared with a prospective mentor(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my and my child’s identity and other relevant information will be shared with the mentor to the extent it aids in facilitating a successful match.

_________________________________________________          _________
Parent/Guardian Signature                                        Date

Mentee Interest Survey
(To Be Completed by Youth and Parent)

What are the most convenient times for you to meet with your mentor? Please check all that apply.

     Weekdays:                  Evenings:                  Weekends:                  Other:  	
 
     Lunch time:                During School:         After school:  

Do you speak any languages other than English? If so, which languages?

What are some favorite things you like to do with other people?

What are your favorite subjects in school?

If you could learn about a job/career, what would it be?

What are your favorite subjects to read about?

What is one goal you have set for the future?

If you could learn something new, what would it be?

What person do you most admire and why?

Describe your ideal Saturday.

			

Please check all activities you are interested in:

	Hiking		Boating		Hunting		Sports		Yoga	
	Fishing		Swimming		Gardening		Park		Movies	
	Animals		Eating		Board Games		Shopping		Technology	
	Golf									

List any other areas of special interest to you and your child. 

Thank You.