Long Island Together

Application Deadline: June 30, 2020

 

Before filling out this application please be sure to carefully read all the information on our main page about the program's requirements and structure (http://longislandtogether.org/partnerup). 

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If you wish to proceed, print out this application, fill it out, and bring it in an envelope addressed to Debbie Harari and drop off at the Our Lady of Fatima Outreach Office, 10 Cottonwood Rd., Manorhaven (if office is closed leave it under the door). Debbie's cell is 917-412-5860.  Or you can mail to Marivic Restivo, 74 Bar Beach Rd., Port Washington, N.Y., 11050. 

 

If you cannot print or have other questions contact Analia Quispe at analia_qt@hotmail.com or 347-444-5210.

 

If your application is accepted, you will receive a call informing you of the date and time of your interview, which will most likely be virtual.

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Student Name: ______________________________________ Grade:_________

 

Age:_______    Date of Birth: _________________ Preferred Pronouns: __________________

 

Address:_____________________________________________________________________

 

Email Address: _____________________________________ Cell #: ____________________

 

Best way to reach you (Email, Text, WhatsApp, etc.): _________________________________

 

Languages spoken other than English:  _____________________________________________

 

Parent/Guardian Name: ______________________________ Cell #: _____________________

 

Relationship: __________________________________________________________________

 

Best way to reach parent/guardian (Email, Text, WhatsApp, etc.): ________________________

 

Referred by (please name the advisor or organization): _________________________________

 

What path(s) are you considering after high school? (You may check more than one choice):

___ 2-year College          

___ 4-year College

___ Other (please specify):_________________________________________________

 

If you made a choice in Question 1, which college major are you considering? (It is ok to write as many as you are interested in!)

 

______________________________________________________________________

 

 

Have you discussed your plans in depth for after high school with anyone such as a guidance counselor, parent or teacher?

 

 

Yes ______ No ______ If yes, please specify with whom: _____________________

 

 

Why are you interested in having a mentor?

 

______________________________________________________________________________________________

 

______________________________________________________________________________________________

 

 

What qualities do you feel are important for your mentor to possess?

 

_______________________________________________________________________________________________

 

_______________________________________________________________________________________________

 

 

Are you working? _________ If so, where? ____________________________________

 

How often (hours/week) ______________

 

 

 

What are your favorite subjects in school?

 

___________________________________________________________________________

 

 

Are there any subjects that you need help with? If yes, please specify.

 

 __________________________________________________________________________

 

 

 

What activities or clubs/organizations are you involved in? _____________________________________________

 

____________________________________________________________________________________________

 

 

Please tell us the time commitment involved in these activities/clubs/organizations.

 

____ 1-3X / Week            ____ 3-6X / Week      _____ Every day

 

 

 

What are your favorite hobbies or interests?

 

______________________________________________________________________________

 

______________________________________________________________________________

 

 

What is your current GPA? (a copy of your transcript or report cards for 9th and 10th grade will be required at interview)

 

_____________

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Do you anticipate any difficulties in meeting with your mentor 1-2 times a month, and            maintaining regular phone and/or text contact at least once weekly?

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____ Yes ____ No

 

 

Do you have people in your life, who are supportive of your plans to go to college?

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____ Yes ____ No ____ Not Sure

 

 

Have you thought about the financial aspect of attending college, paying for tuition, room

and board, books?  ______Yes _______No               If Yes, how would you pay for it?

 

____ Loan ____ Scholarship ____ Parents ____Work

 

 

Is there anything else you feel would be important for us to know about you? (awards, commendations, family circumstances, etc.)

 

 

____________________________________________________________________________________________

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____________________________________________________________________________________________

 

 

 

 

If you are accepted in PARTNER UP, do you give your consent to share this application form with your mentor? (Your answer will not impact your acceptance one way or the other)

 

____ Yes ____ No

 

 

I certify to the best of my ability that the information provided on this application is true and accurate.

 

I certify to the best of my ability that I am fully committed to my success in the

PARTNER UP Mentor Program.

 

 

_____________________________________                      _____________________

Mentee Signature                                                                    Date

 

 

 

 

FOR PARENT OR GUARDIAN
 

I consent to have my child participate in the PARTNER UP mentoring program and understand that I will be supportive of my child to make this process a success. I release PARTNER UP of all liability for injury or other damages that may result from my child’s participation in the program and hold harmless any PARTNER UP mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

 

 

 

____________________________________________________________________

Parent/Guardian Name (Please print clearly)

 

 

____________________________________                        ____________________

      Parent/Guardian Signature                                                     Date