:: NYC Mentee Summer Application

Contact Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone*

Email*

Background Information

Date of Birth*

What is your gender?*

What ethnic group do you identify as*

Please hold down the "Ctrl" button and click all of the choices that apply to you.

How did you hear about StreetWise?*

If you were referred by a social service agency, training program, college, or other organization, what is the name of the organization that referred you?

If you were referred by an alumni or volunteer, what is their name?

Are you a U.S. Citizen?*

Yes
No

If you are not a U.S. citizen, what documents allow you to work legally in the U.S.?*

If you are a U.S. citizen select "Not Applicable"

If other, please explain

Is English your first language?*

Yes
No

Are you a first generation American or recent immigrant?*

Are you the first person in your family to go to college?*

Have you ever served in the United States Armed Forces?*

Please indicate your marital status*

Are you a caretaker and/or responsible for anyone under the age of 18?*

Yes
No

Financial Information

How much money did you make in the last year?*

Please estimate to the best of your ability

How many people are you financially supporting?*

This includes yourself

What was your household income last year?*

This includes spouse or family members living in your home.

How many people are in your household?*

This includes spouse/partner, parents, siblings, children, extended family, etc.

Is anyone else financially supporting you?*

Yes
No

Social Services

Do you receive any social services?*

Yes
No

Please select all services you receive.*

Please hold down the "Ctrl" button and click all of the choices that apply to you.
If you do not receive social services select "Not Applicable".

Do you have a history of substance abuse?*

This will not affect your eligibility for the program. It will help us match you with a mentor.

Yes
No

Have you ever been convicted of a crime?*

This will not affect your eligibility for the program. It will help us match you with a mentor.

Yes
No

If you have been convicted of a crime please explain:

Employment

Are you currently employed?*

Yes
No

Which one of the following shifts do you work?*

If you are not currently working select "Not Applicable"

Name of Employer*

If you have more than one indicate your primary employer. If you are not employed write "Not Applicable".

What is your job title?*

If none, write "Not Applicable"

Are you currently looking for employment?*

Yes
No

What shifts are you looking to work?*

Please hold down the "Ctrl" button and click all of the choices that apply to you.
If you are not looking for work select "Not Applicable".

What industry are you most interested in?*

Education

What is your highest level of education completed?*

Are you currently enrolled in college?*

Yes
No

Name of College

What level of college degree are you pursuing?

If you are not pursuing a degree select "Not Applicable"

What year of college are you currently in?

If you are not currently pursuing a degree select "Not Applicable"

If you have a college degree what is the name of the college you graduated from?

Have you ever attended a skills training program?*

Ex: Per Scholas, STRIVE, Year Up, etc

If yes, which program(s) and when did you attend/graduate?

Please include all that you've attended

Computer Skills

Do you have regular access to a computer?*

Yes
No

Do you have regular access to internet?*

Yes
No

My signature indicates that all information in my application is complete, factually correct, and honestly presented.*

Please write your full name, no initials.