User login

Empire Mentorship Initiative Mentee Application

1 Start 2 Complete
Mentee Applicant
Extended Demographics
EMI Mentee Application
How did you hear about us?
What are your personal interests, skills, sports or hobbies?
Are you a student?
If yes, what school do you attend?
Are you having any problems at school?
If yes, explain:
EMI Mentee Consent and Release
We, the undersigned, hereby consent to the use of any tapes, photographs, slides, tape recording, or any Other visual or audio reproduction in which the undersigned may appear for The Empire Mentorship Initiative to be used, distributed or shown as they see fit. We understand that the photographs, or voice may be used by The Empire Mentorship Initiative as part of a program to recruit volunteers and to provide information to the community about The Empire Mentorship Initiative, and we release Empire Mentorship Initiative from any liability connected with the use Of the pictures, or voice recording as part of any such recruitment program.
EMI Mentee Parental Release
l, the parent/guardian do hereby give my consent and permission for the above named young person to participate in The Empire Mentorship Initiative, including any related activities or events. I further release The Empire Mentorship Initiative and their paid and volunteer staff from all liability for any injuries or accidents resulting from any sickness, injury, or accident. Treatment for any illness or injury will be the financial responsibility of the undersigned parent or legal guardian. I hereby authorize the official representative of The Empire Mentorship Initiative to approve emergency medical or surgical care during any related activities or events in the event the parent or guardian cannot be contacted.