Defy youth mentor application
ESTATE BOVONI – TUTU HI-RISE WEED AND SEED GROVE PLACE WEED AND SEED Tel# 340-776-1525 STT 340-201-9097 STX YOUTH MENTOR APPLICATION DRUG EDUCATION FOR YOUTH Coordinator Use Only Date Received: __________ Application #: ___________ Please type or print legibly – To be completed by Parent or Guardian Mentor’s Name: __________________________________________ Age _____ DOB: ___/ ___/_____ Mentor’s Address: _____________________________________________________________________ Mentor’s Email Address: _________________________________________________________________ Name of Mentor’s School: _____ __________________________________________________________ Last Grade attended________________________ Promoted ________________ Retained ____________ Father’s Name: _______________________________________________________________________ Father’s Address: ___ ___________________________________________________________________ Work Phone: ( ) _______________ Home Phone: ( ) ______________________________________ Email Address: ________________________________________________________________________ …
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ESTATE BOVONI – TUTU HI-RISE WEED AND SEED GROVE PLACE WEED AND SEED Tel# 340-776-1525 STT 340-201-9097 STX YOUTH MENTOR APPLICATION DRUG EDUCATION FOR YOUTH Coordinator Use Only Date Received: __________ Application #: ___________ Please type or print legibly – To be completed by Parent or Guardian Mentor’s Name: __________________________________________ Age _____ DOB: ___/ ___/_____ Mentor’s Address: _____________________________________________________________________ Mentor’s Email Address: _________________________________________________________________ Name of Mentor’s School: _____ __________________________________________________________ Last Grade attended________________________ Promoted ________________ Retained ____________ Father’s Name: _______________________________________________________________________ Father’s Address: ___ ___________________________________________________________________ Work Phone: ( ) _______________ Home Phone: ( ) ______________________________________ Email Address: ________________________________________________________________________ Mother’s Name: ___ ____________________________________________________________________ Mother’s Address: _____ ________________________________________________________________ Mother’s Work Phone: ( ) __________ Home Phone: (____) __________________________________ Email Address: ________________________________________________________________________ Legal Guardian’s Name: _____ ____________________________________________________________ Legal Guardian’s Address: _____.__________________________________________________________ Guardians Work Phone: (____) _______________________________ Home Phone: (_____) __________ Email Address: ________________________________________________________________________ Previous DEFY Attendance Yes _______ No ________ Where ______________________ By my signature, I agree to make the youth applicant available for the Phase I Summer Leadership Camp and the Phase II School - Year Mentoring Component. I also agree to participate in any and all program measures of effectiveness studies, surveys, and questionnaires to further improve the quality of the Program. Signature ____________________________________ Date ___________________________