Mentee Application

Eye to Eye
Eye to Eye Mentee Application
Dear Parents and Guardians,
 
Your student has the opportunity to work with an Eye to Eye Mentor, a trained college or high school student with learning differences or ADHD who will work with your student, one-on-one, throughout the school year to improve social-emotional skills like self-esteem, self-advocacy, and perseverance.
 
Eye to Eye Mentors will visit your student’s school once per week and use an arts-based curriculum designed to promote social-emotional development.
 
As a parent/guardian of a Mentee, you will be invited to two events celebrating the Eye to Eye Mentors and Mentees: a Winter Celebration (before holiday break) and an Art Show and Graduation (at the end of the school year). At these events, you can meet your student’s Mentor and see what they have been doing and learning in the Eye to Eye program.

To register your student in Eye to Eye, please completed the following Mentee Enrollment Form.

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Eye to Eye
To be Completed by Mentee's Parent/Guardian
Mentee Information



















Parent/Guardian Contact Info










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Eye to Eye
To be Completed by Mentee's Parent/Guardian
Optional Questions
The following questions are optional. Your answers allow Eye to Eye to better understand the students we serve and to ensure we serve a diverse group of Mentees.





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Eye to Eye
To be Completed by Mentee's Parent/Guardian
Transportation & Trusted Adults
Note: If Eye to Eye takes place during the regular school day, please leave this section blank.

Note: All parents, guardians, and trusted adults must show their driver’s license and provide their signature for the Eye to Eye Chapter Leader to release the student each week. Eye to Eye Chapter Leaders and Mentors are not permitted to transport Mentees to or from schools.
I authorize Eye to Eye to release my student to the following trusted adults:
Trusted Adult



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Eye to Eye
To be Completed by Mentee's Parent/Guardian
Consent to Participate & Release of Liability
I give my informed consent and permission for my student to participate in Eye to Eye’s programs and related activities. I agree to have my student follow all program guidelines and understand that any violation may result in suspension and/or removal from the program.  I release Eye to Eye of all liability of injury, death, or other damages to me, my student, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any Eye to Eye volunteer, staff member, or other representative, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.  
 
I agree to allow Eye to Eye to use images and video of my student, with his or her first name, taken while participating in the program for Eye to Eye educational and promotional purposes.  I understand that Eye to Eye also collects academic, social-emotional, and behavioral data to evaluate the quality of its programs by surveying its participants regularly.  I understand that participation is completely voluntary, my student’s responses are anonymous, and my student does not have to answer any question he or she would rather not answer.  


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