Life Launch Mentee Application
PERSONAL
First Name *
Last Name *
Gender *
Female
Male
Age *
Birth Date *
Social Security #
Address 1 *
City *
State *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
U.S. Minor Outlying Islands
Virgin Islands
Armed Forces Americas
Armed Forces Europe, the Middle East, an
Armed Forces Pacific
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut Territory
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Zip *
Email
Cell Phone *
Home Phone
Other Phone
Race/Ethnicity *
African American American Indian Asian Caucasian Hispanic/Latino Native Hawaiian/Pacific Islander Blended
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? *
Yes
No
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? *
Yes
No
Company Name
Full-time or part-time
Full-time
Part-time
Hours/week
Location
Position
Salary/Hour
Do you have health insurance? *
Yes
No
Are you looking for work? *
Yes
No
PERSONAL
Have you ever been homeless? *
Yes
No
Have either of your parents been incarcerated?
Mom *
Yes
No
Unknown
Dad *
Yes
No
Unknown
Have you ever been convicted of a felony? *
Yes
No
Do you currently take prescription medication? *
Yes
No
If yes, please state reason for each medication. *
RELIGION
Do you have a spiritual preference? *
Yes
No
Are you involved in a local Church? *
Please give the location of the Church. *
How interested are you in learning more about God and how to grow spiritually? *
Have you had a previous mentor relationship with a person or organization? *
Yes
No
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.
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.
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.
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.
5. ESSENTIAL DOCUMENTS - Social security card, birth certificate, photo ID. Other essential documents may include: CDIB card, insurance card, etc.
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.
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.
8. OTHER INDEPENDENT LIVING SUPPORTS - Money management, banking, legal aide, etc.:
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. *
PERSONAL INTERESTS
If I could go anywhere in the world, I would go [where] and see [what]? *
AVAILABILITY
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? *
Your most important relationship is with who? What is their relationship to you? *
Another important relationship is 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 *
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