1 Start 2 Complete Mentee Applicant First Name Last Name Gender Birth Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Phone Number Phone Number 2 Street Address City State/Province Postal Code Email Extended Demographics Ethnicity EMI Mentee Application How did you hear about us? How did you hear about us? What are your personal interests, skills, sports or hobbies? What are your personal interests, skills, sports or hobbies? Are you a student? Yes No Are you a student? If yes, what school do you attend? If yes, what school do you attend? Are you having any problems at school? Yes No Are you having any problems at school? If yes, explain problem(s): If yes, explain: Have you experienced any abuse (physical, sexual, emotional, etc.)? Yes No If yes, explain abuse: Have you had any history Of drug or alcohol use? Yes No Have you ever been arrested? Yes No Do you have a health problem or a physical disability? Yes No If yes, please explain problem and/or disability: Are you taking any medications? Yes No If yes, please list and describe each medication: Do you have a parent or relative in prison? Yes No Anything else you would like to tell us about yourself? Parent/Guardian 1 First Name: Parent/Guardian 1 Last Name: Parent/Guardian 1 Phone Number: Parent/Guardian 1 Email: Parent/Guardian 2 First Name: Parent/Guardian 2 Last Name: Parent/Guardian 2 Phone Number: Parent/Guardian 2 Email: Consent Consent to Contact Yes No EMI Mentee Consent and Release Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071207220732074 The undersigned (mentee) 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. Consented to by parent/legal guardian: Mentee Name EMI Mentee Parental Release Mentee Name Personal Physician Affiliated Hospital Insurance Coverage Policy No. Date Signed Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071207220732074 Parent/Legal Guardian Name 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. Parent/Legal Guardian Address Parent/Legal Guardian City Parent/Legal Guardian State Parent/Legal Guardian Zip Parent/Legal Guardian Phone
