Hours of Operation

Monday - Friday 8:00am - 9:00pm with the exception of Wednesday the clinic is open from 8:00am - 12:00pm, and 5:00pm - 9:00pm.

Saturday - 9:00am - 1:00pm

Youth Mentoring Program

Mentee Application

(To be Completed by the Parent/Guardian}

Personal Information

Youth's Name:

Date:

Parent/Guardian Name:

Relationship to Youth:

Mother

Father

Other, Specify

Street Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Youth Social Sec. #:

Date of Birth:

Age:

Gender:

Male

Female

Ethnicity:

Native

Hispanic

African American

Other

Name of School:

Grade:

Emergency Contact Name:

Phone Number:

Please list all members of your household

Name	Sex	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.

1. Why do you/your child want to participate in a Mentoring program?

2. Briefly describe your expectations for the Youth Mentoring Program:

3. Is your child available to meet with a Mentor four hours per month and have contact at least once a week for a minimum of one year? Please explain any particular scheduling issues.

4. Is your child willing to attend an initial Mentee training session and two in-service training sessions per year after being matched?

5. Describe your child’s school performance including grades, homework, attendance, behaviors, etc.:

6. Does your child have friends? Please describe his/her friendships.

7. Is your child currently having any problems either at home or school?

8. Has your child experienced any traumatic events (i.e., death in the family, abuse, divorce)? If yes, please provide details.

9. Can you provide any additional background information that may be helpful to the Youth Mentoring Program in matching your son/daughter with an appropriate Mentor?

Medical History

Name of Primary Care Physician:

Phone Number:

Medical Insurance Provider:

Policy Number:

Phone Number:

Does your son/daughter have any physical problems or limitations?

Is your son/daughter currently receiving treatment for any medical issues?

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

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

Does your son/daughter have any emotional issues or problems right now?

Is your son or daughter currently seeing a counselor or therapist?

Therapist's Name:

Please read this carefully before signing:
Youth Mentoring Program appreciates you and your child’s interest in becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their son/daughter to participate in the Youth Mentoring Program.

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:

I give my informed consent and permission for my child to participate in the Youth 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 his/her Mentor and/or First Nations Community HealthSource staff while participating in the Youth Mentoring Program, and that such transportation is voluntary and at his/her own risk.

I release the Youth Mentoring Program/First Nations Community HealthSource of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any Youth 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 First Nations Community HealthSource 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 materials.

I understand I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of my application being processed:

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

Please return or mail this application and the items listed above to Youth Mentoring, First Nations Community HealthSource,5608 Zuni Rd SE, Albuquerque, NM 87108.