LGI – EPIC Mentee Application

THE LIFEGOLD INITIATIVE - MENTEE APPLICATION (EPIC)
*Applicant must be a pregnant or parenting female age 12-24 with a child 5 years or younger to apply.

APPLICANT INFORMATION

(Type "None" if no other aliases)

APPLICANT HEALTH INFORMATION

APPLICANT EMPLOYMENT & EDUCATION

APPLICANT PREVIOUS MENTORSHIP EXPERIENCE

APPLICANT PRE-MATCH QUESTIONNAIRE (Responses are used for mentor/mentee matching)

Type "None" if there is nothing additional to add.
Type "None" if there is nothing additional to add.

EMERGENCY CONTACT

APPLICANT ACKNOWLEDGEMENTS AND SIGNATURE

If the applicant is a Minor, a Parent or Guardian must complete the "Parent/Guardian" sections below.
By signing and submitting this application, I hereby attest that I have read, understand, and agree to the acknowledgments above, that the information I have provided on this application is complete and accurate, that I have not omitted any information that should be disclosed in consideration of my application to participate in the mentoring program selected above. I understand that LGI is not obligated to provide a reason for the final decision regarding acceptance or rejection of this application and that all information provided herein is confidential unless disclosure is required by law. I further understand that the application in its entirety becomes the property of LGI.
We will request a copy of your CA ID, and your photo upon acceptance of your application.

LEGAL PARENT/GUARDIAN INFORMATION (if applicant is a minor)

Type "None" if there is nothing additional to add.
Type "None" if there is nothing additional to add.
Type "None" if there is nothing additional to add.

PARENT/GUARDIAN ACKNOWLEDGEMENTS AND SIGNATURE

To be completed by the legal parent/guardian if applicant is a minor. By signing and submitting this application you agree the following:
Type your legal name above to sign the application. By signing and submitting this application, I hereby attest that I have read, understand, and agree to the acknowledgments above, that the information I have provided on this application is complete and accurate, that I have not omitted any information that should be disclosed in consideration of this application for myself or my child to participate in the mentoring program selected above. I understand that LGI is not obligated to provide a reason for the final decision regarding acceptance or rejection of this application and that all information provided herein is confidential unless disclosure is required by law. I further understand that the application in its entirety becomes the property of LGI.
*If you provided a cell phone# above, our team will send updates about LGI programs and events via text message.