2018-2019 Mentee Application

Please note, you cannot save this form. It must be completed and submitted in one session. We recommend working on your answers in a separate document and inputting them all at once. Questions or technological issues? Contact Valerie Imus at [email protected].

Youth Information

Full Name *

Date of birth *

MM/DD/YYYY

Address *

City *

State *

Zip *

Home phone *

(XXX) XXX-XXXX

Cell phone *

(XXX) XXX-XXXX

E-mail *

School *

Grade *

What languages do you speak? *

What is the easiest way to regularly contact you? *

By email, text message, etc.

Youth Application

Tell us about yourself, your artistic interests, and anything else that’s important to you. We want to be sure to make the best possible mentor match for you!

What experiences have you had with art? *

Do you participate in any extra-curricular activities outside of school? *

If yes, which ones?

What do you like to do in your free time? *

Why do you want a mentor? What do you hope to learn? *

How did you hear about Southern Exposure’s One-On-One Mentorship Program? *

Parent/Guardian/Emergency Contact Information

Parent/Guardian Full Name *

Parent/Guardian Phone Number *

(XXX) XXX-XXXX

Hit "Submit" only once! Please give the system time to process your application. Do not navigate away from this page until you get a confirmation message.

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Youth Information

Youth Application

Parent/Guardian/Emergency Contact Information