Guardian Intake Form

Mentee First Name

Mentee Last Name

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Date of Birth

Home Street Address

City

State

Zip Code

Preferred Phone Number

Phone Number

Preferred Email Address

Email Address

Name of School

Emergency Contact Name (other than primary guardian)

Emergency Contact Relationship to Mentee

Emergency Contact Phone Number

Please list all members of your household. Include Name, Age, and Relationship to the Mentee

What is your occupation? What is your partner's occupation (if applicable)? Do you and your family members have health insurance?

Application Questions

Why do you and your child want to participate in a mentoring program?

Please describe your family's experience with cancer. Who has been diagnosed with cancer? What type of cancer? What are the current circumstances?

Briefly describe your expectations for Walk With Sally?

Is your child available to meet to meet with a mentor eight hours per month and have contact at least once a week for a minimum of one year? Please explain any scheduling issues.

Please list all days/times that your child is available to meet with their mentor

Weekdays after schoolWeekday eveningsSaturdaySunday

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

Additional comments:

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

Can you provide any additional background information that may be helpful to Walk With Sally in matching your child with an appropriate mentor?

Do you have a gender preference for your child's mentor? If so, please list.

Medical Information

Name of child's Primary Care Physician

Phone Number

Does your son/daughter have any physical problems or limitations?

Is your son/daughter currently receiving treatment for any medical issues?

Is he/she currently on any type of medication? If so, please specify.

Does your son/daughter have any known allergies or adverse reactions to medications? If yes, please describe them below:

Does your son/daughter have any emotional issues or problems right now?

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:

I give my informed consent and permission for my child to participate in the Walk With Sally mentoring 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 hereby acknowledge that my child will be transported by his/her mentor and/or Walk With Sally staff or representatives while participating in the Walk With Sally mentoring program, and that such transportation is voluntary and at his/her own risk.

I release the Walk With Sally mentoring program of all liability of injury, death, or other damages to me, my child, 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 Walk With Sally mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

(optional) I agree to allow Walk With Sally 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.

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

Parent/Guardian Signature

Date

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.

Parent/Guardian Signature

Date

Guardian Intake Form

Background Information