2026 Life Launch MENTEE Application

Life Launch Mentee Application

First Name *

Last Name *

Email *

PERSONAL

Marital Status *

Single

Engaged

Married

Separated

Divorced

Widowed

EMERGENCY CONTACT

Contact's Name *

Address

City, State, Zip Code

Contact's Phone *

EDUCATION

Are you currently attending school? *

Name of school

Education *

High School Diploma

GED

Other

I am interested in completing:

High School Diploma

GED

Associate Degree

Bachelors Degree

Other

EMPLOYMENT

Currently employed? *

Company Name

Full-time or part-time

Hours/week

Location

Position

Salary/Hour

Do you have health insurance? *

If you are not employed, how are you supporting yourself?

Are you looking for work? *

If not, please explain.

PERSONAL

Have you ever been homeless? *

If yes, how long?

Have either of your parents been incarcerated?

Mom *

Dad *

Have you ever been convicted of a felony? *

RELIGION

Do you have a spiritual preference? *

Are you interested in learning more about God and how to grow spiritually? *

Do you pray? *

Do you feel God is active in your life? *

Have you had a previous mentor relationship with a person or organization? *

If so, when and where? *

PERSONAL NEEDS AND GOALS - Please let us know if you have achieved the goals and needs below or if you still would like to achieve them.

1. HOUSING - Safe and affordable housing, with your name on the lease.

1. My needs/goals: *

2. HEALTH - Vision, dental and anything that affects your body and mind including medication, medical care/insurance, addiction recovery counseling and/or meetings, and counseling to help process and heal from previous trauma.

2. My needs/goals: *

3. EMPLOYMENT - Employment that pays enough to cover all your monthly expenses, including how to look for work, fill out an application, conduct an interview, etc.

3. My needs/goals: *

4. EDUCATION - Anything from completing a GED to attending or finishing college or a vocational program, or any other specific courses or training to help get a better paying job or promotion.

4. My needs/goals: *

5. ESSENTIAL DOCUMENTS - Social security card, birth certificate, photo ID. Other essential documents may include: CDIB card, insurance card, etc.

5. My needs/goals: *

6. TRANSPORTATION - A reliable and affordable way to get to work or school and take care of all your obligations. Also includes learning to drive, getting a driver's license, learning how to ride the bus.

6. My needs/goals: *

7. SOCIAL SUPPORT NETWORKS - People or programs you can really count on to support you when you need it, and who don't require you to give them something in return. Also includes groups or programs that encourage you or give you special support.

7. My needs/goals: *

8. OTHER INDEPENDENT LIVING SUPPORTS - Money management, banking, legal aide, etc.:

8. My needs/goals: *

What do you consider to be your personal strengths? *

What are some areas in need of personal improvement? *

VISION STATEMENT

A vision statement is a simple sentence or short paragraph that states what you would like to achieve or accomplish, and what your future life looks like when you are 25 or 30 years old. My vision statement is: *

How did you learn about Life Launch? *

Why do you want to be part of the Life Launch program? *

Describe your idea of a good and healthy relationship. *

On a scale of 1-10, how respected to you feel by the adults in your life? *

Do you feel listened to or validated by the adults in your life? *

What makes you feel this way? *

Are you able and willing to commit to meeting with your mentors at least 2 times each month for 1 1/2 hours each time? *

Yes

No

AVAILABILITY

What days are you AVAILABLE to meet with your Mentor? *

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

What days are you ABSOLUTELY NOT available to meet with your Mentor? *

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

PERSONAL INTERESTS

Are you more talkative or quiet? *

Talkative

Quiet

Are you more funny or serious? *

Funny

Serious

Are you more energetic or laid back? *

Energetic

Laid back

3 other words that describe me are: *

When I have a choice, my top 2 favorite types of movies are: *

Action

Biography/True story

Comedy

Romance

Scary

If I could go anywhere in the world I would go [where] and see [what]? *

Do you like to play and/or watch sports? What kind? *

If you like to watch TV, what types of shows? *

If you play music, what genre? *

If you make music, what type? *

If you like to read, what types of books or articles? *

If you like to play video games, what kind? *

If you like to draw or paint, what do you like? *

If you like to write or compose, what kind? *

If you like to go shopping, for what? *

If you like to eat, what are your favorite types of food? *

Other? Describe.

Your most important relationships are with who? What is their relationship to you? *

In your opinion, what characteristics of a mentor would be the best fit for you? (e.g., young/old/both; male/female/both; ethnic preferences):

For me, the things that matter most in life are: *

Something else you should know about me is: *

I hereby grant Stand in the Gap permission to use my likeness in a photograph in any and all of its publications, including but not limited to Stand in the Gap's printed, social media related, and other digital publications. I understand and agree that any photograph using my likeness will become property of Stand in the Gap when submitted to staff or when the photograph is taken by a staff member or representative of Stand in the Gap.

I acknowledge that my participation is voluntary, and I will receive no financial compenstion. I authorize Stand in the Gap to edit, alter, copy, publish, and distribute photos for purposes of publicizing Stand in the Gap's program or other related purposes. I waive the right to royalties or any other compensation arising or related to the use of the photograph. I release Stand in the Gap from all claims and demands which may arise from those acting on behalf of myself or on behalf of my estate.

Name *

Today's Date *

When you hit the "Submit" button you will be taken to the next page of this survey.

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