Youth Mentee Application - Jewish Family and Children’s Service of Minneapolis

Mentee Information

Name*

First Last

Family Information

Parent/Guardian Name*

First Last

Parent/Guardian Email*

Enter Email Confirm Email

Ok to leave a message?*

Yes
No

Would you like to receive text messages?*

Yes
No

Address*

Street Address Address Line 2 City State ZIP Code

Best way to reach you*

Call
Text
Email

Best time to reach you*

AM
PM

Additional Parent/Guardian Name

First Last

Parent/Guardian Email

Enter Email Confirm Email

Ok to leave a message?

Yes
No

Would you like to receive text messages?

Yes
No

Address

Street Address Address Line 2 City State ZIP Code

Best way to reach you

Call
Text
Email

Best time to reach you

AM
PM

Siblings

Does the Mentee have any siblings?*

Yes
No

Name*

First Last

Living in the home with mentee?*

Yes
No

Would you like to add an additional sibling?*

Yes
No

Name*

First Last

Living in the home with mentee?*

Yes
No

Personality and Interests

Which of the words below describe your child’s personality?*

(Check all that apply)

If other, please specify*

Check all activities/ areas of interest:*

If other, please specify*

*Please note: Your responses to these questions will not impact your child’s eligibility to be a mentee in our program. These answers help us to best match you with an appropriate mentor.

How would this child benefit from having a mentor?*

What goals do you have for your child and their mentor to work towards?*

(learn something new, spend more time outdoors, have fun, etc.)

Deal Breakers for your child*

(child is afraid of dogs, child is allergic to cats, etc.)

Does your child have any the following disabilities?*

(Check all that apply)

Physical Disabilities (such as hearing loss, wheelchair use, etc.)
Developmental Disabilities (such as Autism Spectrum Disorder, cerebral palsy, etc.)
Mental health diagnoses (such as ADHD, anxiety, depression, etc.)
Learning Disabilities
Medical Conditions
Allergies (including food allergies)
None of the above

Please specify*

Pre-Interview Questions

Do you have any concerns about your family’s ability to fulfill the 12- month commitment required of mentees?*

Yes
No

If YES, please explain.*

Have you had or do you anticipate having any significant life changes over the next year?*

Yes
No

If YES, please explain.*

Do you have any health factors (mental, physical, or emotional) that could impact your ability to engage with a mentor?*

Yes
No

If YES, please explain.*

General Information

How did you learn about our volunteer program?*

Select all that apply.

If other, please specify*

Parent/Guardian Permission*

I agree to the following:

I give my permission for my child to participate in the Jewish Youth Mentoring Program (JYMP). I understand that JYMP is not obligated to match my child with a volunteer mentor and that, as part of the enrollment process, I will be asked to provide personal information. If my child is matched with a mentor, I agree to support their match and to immediately report any concerns I might have to the Jewish Youth Mentoring Program staff.

Date*