Friends for Youth Initiative - Mentee Middle School Sign-up Sheet (Fillable) (PDF)

Friends for Youth Initiative (FYI)  in partnership with
Dominion’s Powered by a Mentor  
Waterford’s Mentoring Partnership
Middle School Student Application
Name: 
 Date of Birth: 
 – 
 – 
Address: 
 City: 
Zip Code: 
 Phone Number: 
Why do you want to have a mentor?
Describe health issues we should be aware of (i.e. allergies, physical limitations, etc.).
What interests and skills do you have (i.e. sports, reading, writing, computers, video games, theater, music, 
mechanical, dirt biking, etc.)?
Grade: 
 Teacher: 
Are you willing to stay after school once a week? 
If so, which days are best?

Parent/Guardian Information
Name: 
 Marital Status: 
No. of Children in Family: 
Student Agreement
I, 
, understand that my mentor and I will have weekly appointments.
If I am not in school or cannot make my appointment, it is my responsibility to the school office or WYSB to 
either cancel or reschedule my appointment with my mentor.
 Signature:                                                                            Date:
Parent/Guardian Agreement
I, 
, understand that my son/daughter is participating in a voluntary 
program that he/she has the opportunity of being selected for. I understand that the mentor that he/she will work 
with will have gone through an intense application process and that the mentor is volunteering his or her time 
weekly to spend with my son/daughter. All sessions will take place at a convenient time and place for both on 
school grounds during school hours. Release of information: I understand that for the program to run 
effectively, it will be necessary for school/WYSB personnel to contact the mentor if my son/daughter is absent 
from school or unable to meet the mentor on the day of the scheduled meeting.
 Signature:                                                                            Date:
*Application adapted from the Connecticut Mentoring Partnership.
For further information and questions contact Dani Gorman, Director, 
Waterford Youth Services, 15 Rope Ferry Road, Waterford, CT 06385;
(860) 444-5848