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Mentee Registration Form

Thank you for your interest in our Mentorship program. Please complete the form below to register ages 12–18 for our specialized Mentorship program. We're excited to have you join our community!

Parent / Guardian Information

Mentee Information (Ages 12–18)

Race/Ethnicity (Check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Two or More Races
Prefer not to say
Other

Interests & Goals

Areas for Adult Mentor to support? *
Social / Emotional Support
Communication Skills
Leadership Skills
Confidence Building
Discovering their Interests
Career Exploration
Life Skills
Conflict Resolution
Other
Preferred days for sessions? *
Wednesday — Gaston Community Center (4–6pm)
Weekends / Special Events Only

Consent & Agreements

Participation and Program Consent: I give permission for my child to participate in the mentorship program offered by Memphis Youth Development Group. I understand mentors are screened and trained but are not licensed therapists or educators. Participation is voluntary.

Media Release: I GRANT permission for MYDG to photograph, record, and use images or recordings of my child for promotional, educational, and reporting purposes.

Transportation: I acknowledge MYDG does not provide transportation and is not liable for transportation-related incidents.

Confidentiality & Mandatory Reporting: Mentors maintain confidentiality except where required by law. MYDG complies with mandatory reporting laws.

Liability Waiver: MYDG, including staff, volunteers, and affiliates, are not responsible for injuries or problems during participation.

By submitting, I confirm all information is accurate and I agree to the terms above.

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Your registration will be sent directly to our team.

Registration Submitted!

Thank you for registering. A member of our team will reach out to you soon with next steps.

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