MAPS
MENTEE APPLICATION
APPLICANT INFORMATION

Name: ______________________________________________________________________

Date of Birth: ________

Phone: __________________

School: _________________________

Current address: ___________________________________________________________________

City: _________________________

State: __________

ZIP Code: _________________

Language Spoken: ____________________

Race/ethnicity: ___________________

Income level: low   middle   high 

PERSONAL INFORMATION

Current employer or school: ____________________________________________________________

School Address: _________________________________________________________

How long? ______________________

Phone: ____________________________

E-mail: __________________________


City: ______________________________

State: _____________

ZIP Code: ________________

Referred By: _______________________

Guardian: ________________________

Guardian Signature: _______________

EMERGENCY CONTACT INFORMATION

Name: ______________________________________________________________________________

Address: _______________________________________________________________

Phone: _________________________

City: _______________________________

State: ____________

ZIP Code: _______________________

Relationship: ________________________________________________

DISABILITY INFORMATION

Type: __________________________________________________________________

Accommodations: ________________________________________________________

Attendant Name (if currently utilizing one) : ___________________________________   
Phone: __________________________

PERSONAL SURVEY INFORMATION
*ALL PERSONAL INFORMATION OBTAINED IS STRICTLY CONFIDENTIAL*
Circle One

Do you want to go out with friends but are too nervous?    Never  Sometimes  Often  Always


Do you have a hard time getting around?                    Never  Sometimes  Often  Always


Do you ever feel alone?                                    Never  Sometimes  Often  Always


Do you ever feel so sad that it prevents you from doing activities?               Never  Sometimes  Often  Always


Would you like to make new friends?                        Never  Sometimes  Often  Always 

Does your disability prevent you from attending activities?                       Never  Sometimes  Often  Always

AGREEMENT
I authorize the verification of the information provided on this form. I have received a copy of this application.



Signature: __________________________________________                                     Date: _____________________