Student Mentorship Application

STUDENT MENTORSHIP APPLICATION

This application is used to evaluate suitability for placement in the Student Mentorship Program. Completion of this form does not guarantee placement. The program reserves the right to verify information provided, contact references, and require additional documentation. Provide complete and truthful responses.

Applicant Information

Date of Birth:    Student ID:    Grade / Program:

Parent / Guardian (if applicant is under 18)

Is the applicant under 18? Please provide parent/guardian contact details below if applicable.

Academic & Program Information

Expected Graduation / Program End Date:

Mentorship Preferences

Preferred mentor attributes (experience, background, skills): Use the field below to identify priority attributes.

Preferred meeting format: In person Virtual Hybrid

Goals & Statement

Eligibility, References & Documents

Check all documents you are attaching or will provide upon request:

Official or unofficial transcript    Recommendation letter(s)    Proof of enrollment / ID

Do you consent to program staff contacting the references provided and verifying enrollment?

Health & Emergency Information

Program Policies & Agreements

Code of Conduct and Confidentiality: If accepted, the applicant agrees to comply with the program's code of conduct, to maintain respectful communication with mentor(s) and staff, and to maintain confidentiality of sensitive mentor-mentee discussions where indicated. The program may remove participants for conduct that threatens safety, violates policy, or disrupts program objectives.

Release and Limitation of Liability: By participating in mentorship activities, the applicant (and parent/guardian if applicant is under 18) releases the program, its agents, and partner volunteers from claims arising from ordinary risks inherent to mentorship activities, except where liability is imposed by law. The applicant acknowledges that participation is voluntary and that the program will make reasonable efforts to minimize risk.

Data Use and Records: Information provided in this application will be used to assess eligibility, match mentors, and administer program operations. The program may maintain records that include contact information, assessment notes, and participation history. The program will handle personal data consistent with applicable privacy obligations.

Acknowledgment: I acknowledge that I have read the policies above and that all information submitted is true and accurate to the best of my knowledge.

I acknowledge and accept the program policies and agreements.

Photo/Media Release: I consent to the use of photos/video for program outreach and materials.   I do not consent.

Criminal Background & Safety

The program may require background checks for mentors and reserves the right to deny placement if safety concerns arise. Applicants should disclose any information that may affect mentor placement or safety evaluations.

Applicant consents to verification of enrollment and contact with references:

Certification

Certification: I certify under penalty of perjury that the information contained in this application is true, complete, and correct. I understand that any misrepresentation may be grounds for denial of participation or removal from the program.

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