BridgeMentoring Mentee Application

Type of mentoring: (Please select only one)

If you are new to the country and have been in the U.S for less than 5 years, please select Refugee Youth Mentoring. If you were born here or have been in the U.S for more than five years, please select BridgeMentoring. *This question is required.

Mentee Information

First Name *This question is required.

Last Name *This question is required.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Street Address *This question is required.

Apt/Suite

City *This question is required.

Zip *This question is required.

Primary Phone Number *This question is required.

Secondary Phone Number

If you said other, please specify.

Country of Birth *This question is required.

If born outside the U.S, please indicate date arrived the U.S. This question requires a valid date format of MM/DD/YYYY.

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Any medical/mental health conditions we should be aware of? *This question is required.

If yes, please specify. *This question is required.

Any allergies? *This question is required.

If yes, please specify. *This question is required.

Preferred language/s *This question is required.

Kinyarwanda
Other

If you said other, please specify.

If you said other, please specify. *This question is required.

Interests *This question is required.

If you said other, please specify.

Has the mentee ever been involved with the Juvenile Justice System? *This question is required.

If yes, provide JCCO name *This question is required.

BridgeMentoring Mentee Application

Welcome