Name First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Date of Birth MM slash DD slash YYYY Phone Number (H-C-W)Phone Number (H-C-W)Phone Number (H-C-W)Which of the following describes you? Check all that apply. I have had experience with the criminal justice system I have experience living in high priority or at-risk neighborhoods I have issues with the school system I have experience living in foster care or transitioning out of foster care I have experience being homeless I have lived in multiple states Are you in school and/or work? School full time School part time Full time employment Part time employment N/A Why do you want to participate in the mentoring program?What do you expect from the mentorship program? What can I do to support your life right now?How much time are you able to dedicate for mentoring per week?Health and Safety InformationDoes the client have medical insurance? Medical Insurance Name: Policy Holder’s Name Date MM slash DD slash YYYY Client’s Physician or Health Clinic: Physician or Health Clinic Telephone #: Does the client have any medical allergies? If yes, please state: Yes No Please state: Is the client on any prescription medications? If yes, please state: Yes No Please state: Please list any physical, mental or health problems we should be aware of? Is there any activity in which the client may not participate in? Thank you for your interest in Impel’s mentoring program and for investing in your own journey.
