Newberg Mentors

PO Box 91., Newberg, OR. 97132 (503)453-7967

Mentee (Child/Youth) Application Name ______________________________________________ Date _______________ Home Address _____________________________________ Home Phone ___________ Street City Zip Birth date __________________________ Racial/ethnic identity ___________________ School you attend ______________________________ Year in School ______________ Parent/guardian ___________________________ Daytime Phone __________________ Emergency Contact _______________________________ Phone __________________

What are three words that would best describe you?

What would like to be when you grow up?

What goals do you have after high school?

Is there anything that you would change about yourself?

Mentor/Mentee Activities and Interests Place an X next to the activities you enjoy doing. Leave blank, items you have absolutely no interest in. Please circle your top 5 choices. Sports ___ Moto Cross ___ Football ___ Baseball ___ Basketball ___ Track ___ Soccer ___ Ping Pong ___ Tennis ___ Volleyball ___ Roller skating ___ Bowling ___ Billiards ___ Swimming/diving ___ Auto racing ___ Wrestling ___ Golf (regular/mini) ___ Handball ___ Hockey ___ Archery ___ Frisbee ___ Racquetball ___ Downhill Skiing ___ Sledding ___ Snowmobiling ___ Marital Arts ___ Cross Country Skiing ___ Ice Skating ___ Ice Fishing ___ Weightlifting Recreation ___ Auto mechanics ___ Walking ___ Hiking ___ Camping ___ Fishing ___ Cooking ___ Picnicking ___ Boating ___ Canoeing ___ Water Skiing ___ Horseback riding ___ Rodeos ___ Motorcycling ___ Bike riding ___ Jogging/running ___ Listens to music ___ Movies ___ Museums ___ Plays ___ Concerts ___ Dancing ___ Reading ___ Stamp Collecting ___ Coin collecting ___ Rock Collecting ___ Model Cars ___ Indoor Games ___ Video Games ___ Musical Instrument ___ Playing Cards ___ Pool, pinball, foosball ___ Singing ___ Acting Science/Technology ___ Study Nature ___ Animal tending/zoo ___ Gardening ___ Rock Climbing ___ Travel/sightseeing ___ Chemistry ___ Astronomy ___ Electronics ___ Computers ___ Photography Other ___ Attending church ___ Speaking foreign languages Arts & Crafts ___ Carving ___ Sewing ___ Crocheting ___ Quilting ___ Woodworking ___ Knitting ___ Macram ___ Painting

MENTEE AGREEMENT We will do our best to match you with a mentor who has similar interests and who we think will be a good match for the upcoming year. You will meet with your mentor 3 or 4 times per month. Your mentor will let you know the times and dates of these fun events. In order to gain the most from the program, you need to make an effort just like the mentor. I understand the following expectations of mentoring.

Signature of mentee:

Date:

PLEASE RETURN THIS COMPLETED FORM TO Newberg Mentors PO Box 91, Newberg, OR. 97132 (503)453-7967

PARENT/GUARDIAN LIABILITY AND RELEASE AGREEMENT I give my approval to Newberg Mentors for release of information regarding my child, __________________________________, in regard to participating in the following (with name included): Photographs, TV & Movies and General Information. I also give my permission for the school to provide social and academic information about my child to Newberg Mentors (e.g. report cards, attendance records, behavior reports, etc.). I understand that no fees are charged for requesting a volunteer, and that it is a privilege for a child to become part of the program. I recognize that the volunteer assumes no legal or financial liability for my child. I also understand that by signing this form I am giving permission for my son/daughter to participate in Newberg Mentors, including all organized activities and transportation. In consideration of the advantages of participation in mentoring, I agree that Newberg Mentors, its agents, and its employees shall be released from any and all liability for any damage or injury which my child might sustain while participating in said programs and activities both as to any right of action that may accrue to my child, or to me as his/her parent/guardian.

Signature of parent/guardian

Date

Print Name

Relationship to child

Address __________________ Home Phone Number

City ________________________ Mobile/Pager Phone Number

Zip __________________________ Work Phone Number

___________________________________ Email Address

_________________________________ Language Spoken by Parent/Guardian

____________________________________________________________________________ Emergency Contact and Phone(s) Will you be able to help with transportation of your child to meet with the mentor? Yes or No
PLEASE RETURN THIS COMPLETED FORM TO Newberg Mentors PO Box 91, Newberg, OR. 97132 (503)453-7967