Focus on the Future Mentorship App

FOCUS ON THE FUTURE

MENTORSHIP PROGRAM APPLICATION

The Mission Statement

The mission of “Focus on the Future” mentoring program is to provide young men with an opportunity to address spirituality, academics, and professionalism. The basis of the program format is a group setting, which would provide the participants with direct connection to a mentor for encouragement, accountability, and growth while being trained in a focused environment. It is with this mission that I hope that we will train the next group of mentors who will lead our communities. There is no cost to participate in this program. We do, however, require a $25 application fee.

Download Focus Info Kit Here.

Motto:

“Mentoring New Leaders, To Build Our Communities”

Core Values:

Spirituality
Academia
Professionalism

PERSONAL INFORMATION (to be completed by the parent/gaurdian)

YOUTH INFORMATION

Youth First Name

Youth Last Name

Date of Birth

Age

Name of School

Grade Level

GAURDIANSHIP

Parent / Gaurdian Name

Relationship

Email Address

Address

Home Phone

Work Phone

Emergency Contact

Emergency Contact Phone

Student Image (for identification)

Upload Picture

Please list all members of your household.

MENTORSHIP QUESTIONS

Please answer all of the following questions as completely as possible.

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

Is your child available to meet with a mentor for at least (8) group sessions. Please explain any particular scheduling issues.

No Yes

My child willing to wear shirt and tie if provided . If no, please explain.

No Yes

Describe your child’s school performance including grades, homework, attendance, behaviors, etc.:

Is your child currently having any problems either at home or school (this will not affect the selection process)?

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 in understanding your child?

MEDICAL HISTORY

YOUTH INFORMATION

Primary Care Physician

Physician Phone

Insurance Provider

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

Does your son/daughter any medical conditions that we should be aware of?

Medications

Known Allergies

I give my informed consent and permission for my child to participate in the Focus on the Future Mentoring Program and all 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 Focus on the Future staff or representatives while participating in the Focus on the Future Mentoring Program, and that such transportation is voluntary and at his/her own risk.

I release the Focus on the Future 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 Focus on the Future mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

I agree to allow Focus on the Future 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.

Your Signature

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