A.C.T., Inc. MENTEE APPLICATION

(Instructions: To sign up for a mentor, print out this form and complete it as accurately as possible. Please print clearly. When completed, just mail it to: Adults Caring for Teens, P.O. Box 354, Nyack, NY 10960. You can also fax it to (845) 358-1877.) An A.C.T. staff person will review it and contact you as soon as possible.

Personal Information:
Male___    Female___
First Name ____________________ Middle Initial ___  Last Name _________________________
Address
Street __________________________ City____________ State __ Zip __________
Home phone:______________________   E-mail Address_________________________________
Father/Guardian’s name ______________________________________
His Work Phone ________________________    Occupation ______________________
Mother/Guardian’s name ______________________________________
Her Work Phone ________________________    Occupation ______________________
Emergency Contact _______________________ Home Phone _____________________
Work Phone _______________________  Relationship ____________________________
 

School Information
1. Name of School: __________________________________________  Grade Level _____
2. List the classes you are taking this year:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
3. What are your favorite subjects?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
4. What subjects do you feel you need help with?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
 

Your Interests
1. What are your hobbies and interests?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

2. Do you participate in any extracurricular activities outside of school (e.g., Boy/Girl Scouts, youth programs)? If yes, explain:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
3. What is your career goal, or what types of careers interest you?
____________________________________________________________________________
____________________________________________________________________________
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4. Do you plan on attending college after you graduate? Yes ____    No ____
5. What would you like to learn more about or becomebaetter at with the help of a mentor
____________________________________________________________________________
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Favorites
What is your favorite...
Food _______________________      Color _______________________
Book _______________________      Movie _______________________
Song _______________________      Person _______________________
 

Match Information
What days of the week are you available to particpate? (Check all that apply):
Monday__   Tuesday__  Wednesday__  Thursday__  Friday__  Saturday__  Sunday__
What is the best time for you to participate? (Check all that apply):
Mornings__   Afternoons__  Evenings__  Weekends__
What three words best describe you? ______________________________________________

Thank you for completing the form. To send it, follow the instructions at the top of the page.