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This is Me Mentee Application

Mentee Information
This question requires a valid date format of MM/DD/YYYY.
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Primary Language: *This question is required.
Secondary Language:
Parent/Guardian Primary Language: *This question is required.
Check the boxes that best describe your child’s personality and/or interests that you’d like the relationship to focus on below. *This question is required.
Are you able to transport/arrange transportation for your child to meet with the mentor on a weekly basis?   *This question is required.
PARENT/GUARDIAN CONSENT AND LIABILITY RELEASE FORM
I, give my consent for This is Me mentoring program to match my child, with a Mentor. I understand that participation will include weekly one-to-one visits (virtual or in person) with the volunteer that has been background checked and trained as a This Is Me Mentor.

I also give consent for my child to participate in all This is Me’s activities; including all organized activities and transportation on group activities. In consideration of the advantages of participation in the This Is Me program, the undersigned agrees that This Is Me, its agents, and its employees shall be released and exempt from any liability for damages for bodily injuries or property damages that may occur as a result of participation in This Is Me, except to the extent of insurance liability as provided by law. I release This Is Me from all claims for injuries or harm incurred while my child is participating in the program.

This Is Me carefully screens volunteers before they are matched with a child. Each new mentor has a background check done by the BCA (299C.62), been interviewed by This Is Me staff member, and attended the New Mentor Training. Although This Is Me carefully selects its volunteers, it assumes no liability for the actions of the volunteers while in the company of your child.

I authorize the school staff, where my child attends, to discuss behavior, social skills and other requested information regarding my child that may help in the matching process or betterment of my child. This includes access to attendance and academic records if necessary.


I have read and understand the above statements. *This question is required.
Signature of Parent/Guardian: *This question is required.
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Signature of
YOUTH AGREEMENT FORM

By choosing to participate in the This Is Me mentoring program I agree to the following:

•    Have a positive attitude and be respectful of my mentor.
•    Make a year-long commitment to being matched with my mentor.
•    Meet once a week with my mentor and obtain parent/guardian permission for all meeting times.
•    Be on time for scheduled meetings, phone calls, or IM meeting or I will call my mentor at least 24 hours before if I am unable to make a meeting.
•    Tell my mentor if I’m comfortable or not with a certain activity.
•    Follow the rules of the program and my parent/guardian.
•    Tell my parent/guardian about the activities my mentor and I do together.
•    Tell my parent/guardian or program staff if I am uncomfortable with the relationship between my mentor and me. I will not get in trouble for feeling this way. Program staff will help me sort out my feelings.
•    Tell my parent/guardian or program staff if my mentor is doing something wrong when I’m with them.
•    Expect my mentor to treat me as a friend. My mentor should not share personal information with others unless there is a possible threat of harm to me or others. 

I understand and agree to follow these policies. *This question is required.
Parents/guardians please sign here after reading and explaining these policies to your child.

Parent/Guardian’s Signature:
  *This question is required.
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