Become A Dreamer : RYP

Personal Information

Application Questions

Please answer all of the following questions as completely as possible

1. Why do you/your child want to participate in the NewLife Youth ReGeneration Program™, ?

2. Briefly describe your expectations for the NewLife Youth ReGeneration Program™.

3. Is your child available to meet with members of RYP and have contact at least once a week for a minimum of one year? Please explain any particular scheduling issues

4. Describe your child's school performance, including grades, homework, attendance, behaviors, etc.

5. Does your child have friends? Please describe his/her friendships.

6. Is your child currently having any problems either at home or at school?

7. Has your child experienced any traumatic events (i.e., death in the family, divorce)? If yes, please provide details.

8. Can you provide any additional background information that may help Realize Your Potential Youth Society offer your son/daughter mentoring services?

Mentee Interest Survey

Please complete all the following. This survey will help Realize Your Potential Youth Society know more about you and your interests and help us find a good match for you.

What are the most convenient times for you to meet with your mentor? Please check all that apply

Do you speak any languages other than English? If so, which languages?

What are some favorite things you like to do with other people?

What are your favorite subjects in school?

If you could learn about a job/career, what would it be?

What are your favorite subjects to read?

What is one goal you have set for the future?

If you could learn something new, what would it be?

What person do you most admire and why?

Describe your ideal Saturday

Please check all activities you are interested in

Please read this carefully before submit

Realize Your Potential Youth Society appreciates you and your child's interest in his/her becoming a mentee. This application is intended to inform and gain the parent/guardian's consent to allow their son/daughter to participate in the NewLife Youth ReGeneration Program™.

After receiving the completed application form, we will evaluate the information and inform you ifyour child has been accepted into the program. The information you supply in this packet will be used to determine your child's eligibility. Therefore, the mentoring staff may, at times, need to access and share this information with other parties when necessary.

I give my informed consent and permission for my child to participate in the NewLife Youth ReGeneration Program™ and its related activities.

I agree to have my child follow all mentoring program guidelines and understand that any violation on my child's part may result in suspension and/or termination of the mentoring relationship.

I agree to allow Realize Your Potential Youth Society to use any photographic image of my child taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.

I understand I must return all of the following completed items along with this application and that any incomplete information will result in the delay of my application being processed:

I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

Contact and Information Release

I hereby grant permission for the Realize Your Potential Youth Society to make contact with my child and conduct a personal interview for the purposes of applying to be a mentee. The Realize Your Potential Youth Society may also make contact with my child on school premises for the purposes of screening and interviewing as well as ongoing support of his/her participation in the mentoring program

I authorize the Realize Your Potential Youth Society to obtain any needed information regarding my child from his/her school's staff, including academic and behavioral records and conversations with teachers, counselors, and other administrative staff

Further, I understand that basic information about my child may be shared with other members of RYP to aid in determining suitable program activities.

Become A Dreamer

Realize Your Potential Youth Society