2020-2021 PARTNER UP Mentee Application
Application Deadline: Monday, Oct. 26, 2020
Before filling out this application please be sure to carefully read all the information on our main page about the program's requirements and structure (http://longislandtogether.org/partnerup).
If you still wish to proceed, print out this application, fill it out, and bring it in an envelope addressed to Debbie Harari and drop off at the Our Lady of Fatima Outreach Office, 10 Cottonwood Rd., Manorhaven (if office is closed leave it under the door). Debbie's cell is 917-412-5860. If you cannot print or have other questions contact Analia Quispe at firstname.lastname@example.org or 347-444-5210.
If your application is accepted, you will receive a call informing you of the date and time of your interview, which will most likely be virtual.
Student Name: ______________________________________ Grade:_________
Age:_______ Date of Birth: _________________ Preferred Pronouns: __________________
Email Address: _____________________________________ Cell #: ____________________
Best way to reach you (Email, Text, WhatsApp, etc.): _________________________________
Languages spoken other than English: _____________________________________________
Parent/Guardian Name: ______________________________ Cell #: _____________________
Best way to reach parent/guardian (Email, Text, WhatsApp, etc.): ________________________
Referred by (please name the advisor or organization): _________________________________
What path(s) are you considering after high school? (You may check more than one choice):
___ 2-year College
___ 4-year College
___ Other (please specify):_________________________________________________
If you made a choice in Question 1, which college major are you considering? (It is ok to write as many as you are interested in!)
Have you discussed your plans in depth for after high school with anyone such as a guidance counselor, parent or teacher?
Yes ______ No ______ If yes, please specify with whom: _____________________
Why are you interested in having a mentor?
What qualities do you feel are important for your mentor to possess?
Are you working? _________ If so, where? ____________________________________
How often (hours/week) ______________
What are your favorite subjects in school?
Are there any subjects that you need help with? If yes, please specify.
What activities or clubs/organizations are you involved in? _____________________________________________
Please tell us the time commitment involved in these activities/clubs/organizations.
____ 1-3X / Week ____ 3-6X / Week _____ Every day
What are your favorite hobbies or interests?
What is your current GPA? (a copy of your transcript or report cards for 9th and 10th grade will be required at interview)
Do you anticipate any difficulties in meeting with your mentor 1-2 times a month, and maintaining regular phone and/or text contact at least once weekly?
____ Yes ____ No
Do you have people in your life, who are supportive of your plans to go to college?
____ Yes ____ No ____ Not Sure
Have you thought about the financial aspect of attending college, paying for tuition, room
and board, books? ______Yes _______No If Yes, how would you pay for it?
____ Loan ____ Scholarship ____ Parents ____Work
Is there anything else you feel would be important for us to know about you? (awards, commendations, family circumstances, etc.)
If you are accepted in PARTNER UP, do you give your consent to share this application form with your mentor? (Your answer will not impact your acceptance one way or the other)
____ Yes ____ No
I certify to the best of my ability that the information provided on this application is true and accurate.
I certify to the best of my ability that I am fully committed to my success in the
PARTNER UP Mentor Program.
Mentee Signature Date
FOR PARENT OR GUARDIAN
I consent to have my child participate in the PARTNER UP mentoring program and understand that I will be supportive of my child to make this process a success. I release PARTNER UP of all liability for injury or other damages that may result from my child’s participation in the program and hold harmless any PARTNER UP mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.
Parent/Guardian Name (Please print clearly)
Parent/Guardian Signature Date