Guardian Intake Form 2021 

Background Information
























Application Questions





Please select a number that accurately describes your child's current level in each area. 










Medical Information








Release of Liability

Please read this carefully before signing:
Walk With Sally appreciates you and your child’s interest in his/her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their son/daughter to participate in the Walk With Sally.
Please know that after receiving this completed application from you, we will evaluate the information and send you a letter letting you know if your child has been accepted into the mentoring program. Much of the information you supply in this application packet will be used to match your child with an appropriate mentor. Therefore, the mentoring staff may, at times, need to access and share this information with prospective mentors and other parties when it is in the best interest of the match. However, we do not reveal names until there is an initial interest from the mentee, parent/guardian, and mentor based first upon anonymous information provided about each other.

Please initial each of the following:





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



Contact Information Release

I hereby grant permission for Walk With Sally to make contact with my child and conduct a personal interview for the purposes of applying to be a mentee. Walk With Sally 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 Walk With Sally 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 will be anonymously (without names) shared with a prospective mentor(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my and my child’s identity and other relevant information will be shared with the mentor to the extent it aids in facilitating a successful match.