2023 Mentee Application 1 Step 1 Choose the Play Like a Girl program to which you are applying:Meet + MentorLeadership AcademySTEM+ Challenge Student Contact Information First Name Last Name Cell Phone(555) 555-5555 Email[email protected]email Street Address Street Address City State Zip Preferred Communication MethodEmailSMS TextTelephone Shirt SizeSelect An OptionYouth SYouth MYouth LAdult SAdult MAdult L Student Personal Information GenderFemaleMale Date of Birthdate_range Race or EthnicityAmerican Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoMultiracialNative Hawaiian/Other Pacific IslanderWhiteUnknownOther, please specify If other race/ethnicity, please specify: Grade in School6th 7th 8th 9th School Name Type of SchoolHome Public Charter Private Other, please specify If other school type, please specify: Program/Match Information Have you participated in a Play Like a Girl program previously? *YesNo What sport(s), if any, do you currently play? *BasketballCheer or tumblingDanceFlag FootballGolfGymnasticsHockeyLacrosseSoccerSoftballTennisVolleyballNoneOther, please specify If other sport, please specify What is your favorite STEM-related subject in school?ArtCodingComputer ScienceDigital Citizenship Entrepreneurship MathematicsRoboticsScienceTechnology Do you own a computer or tablet?YesNo Are you able to access Wi-Fi/internet at home?YesNo Do you plan to attend college or university?YesNo Will you be the first in your family to attend college or university?YesNo Please describe your ideal mentor in one sentence. Please list the top 3 topics or issues you would like to address with your mentors and peers.0 / Please rank the program formats listed below in order of preference, with 1 as the ‘most preferred format, to 3 as the ‘least preferred format.123OnlineLive, In personHybrid (live and online) How often would you prefer to meet with your mentors and peers?Once a weekTwice a monthOnce a month What days and times would you prefer to meet with your mentors and peers?Tuesday - Thursday after school, 3-5pmTuesday - Thursday after school, 4-6pmTuesday - Thursday after school, 5-7pmSaturday morning/early afternoon, 10am-1pm What is your current Time Zone?Pacific Mountain Central Eastern Parent/Guardian InformationThis section of the application should be completed by a parent, guardian or other responsible adult. First Name Last Name Cell Phone(555) 555-5555 Email[email protected]email Relationship to StudentParentGuardianTeacherCounselorCoachOther (please specify) If other, please specify GenderFemaleMale AgeSelect An Option18-2425-3435-4445-5455-6465+ Race or EthnicityAmerican Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoMultiracialNative Hawaiian/Other Pacific IslanderWhiteUnknownOther, please specify If other race or ethnicity, please specify Highest Level of Education CompletedSelect An OptionMiddle SchoolHigh School DiplomaVocational/Technical CertificateTwo-Year College (Associate) DegreeBachelor's DegreeMasters DegreeDoctoral Degree Marital Statuspick one!MarriedWidowedDivorcedSeparatedNever Married Employment StatusEmployed, full timeEmployed, part timeNot employedRetiredDisabled Title Employer Home OwnershipRentOwn Annual Household Incomepick one!Select An OptionLess than $20,000$20,000 to $34,000$35,000 to $49,000$50,000 to $74,999$75,000 to $99,999$100,000 to $149,999More than $150,000 Please rank the following social media sites in order of your usage, with 1 as the ‘most used' to 5 as the ‘least'.12345FacebookInstagramLinkedInTikTok Twitter How did you hear about Play Like a Girl?Select An OptionFacebookInstagramEmail/NewsletterWebsiteFriends or FamilySchool or TeacherOther OrganizationOther, please specify If other please specify keyboard_arrow_leftPrevious Nextkeyboard_arrow_right Do you want to apply to be a Mentor? Apply here.
