TEN:14 Mentee Application

*Address Line 1
Address Line 2
*Zip/Postal Code
The TEN:14 Ministry is a ministry of McLean Bible Church providing mentors to children in Arlington.  As servants of Jesus Christ, the mentors aim to reflect Christ’s love for children. We do so by providing mentorship opportunities that encourage youth to discover and develop their interests and abilities. By caring for local children and their families, our purpose is also to strengthen and nurture Arlington neighborhoods.   If you live in the zip codes: 22041 or 22204 and would like for your child to be involved in the ministry, please complete the information below.
*Child's First Name:
*Child's Last Name:
*Child's Nickname:
*Child's Date of Birth:
*Gender of Child:
*Parent/Guardian Name:
*Relationship to Applicant:
*Street Address:
*Zip Code:
Parent/Guardian Information
*Parent/Guardian Email Address:
*Parent/Guardian Primary Phone Number:
*Emergency Contact First & Last Name:
*Emergency Contact Phone Number:
2nd Emergency Contact First & Last Name:
2nd Emergency Contact Phone Number:
*Please list all members of your household include the name, gender, and age for each person. Example: Emily, female, age 8
*Name of Primary Care Doctor:
*Doctor's Phone Number:
*Medical Insurance Provider:
*Medical Insurance Provider Phone Number:
*Policy Number:
*Does your child have any specific medical needs?
*Does your child have any specific dietary restrictions, dietary needs, or allergies?
*Name of School:
*What grade is the child currently in or entering into?:
Teacher's Name:
*What language does the child know best?
What is the child's seconday language? (if any):
What is the dominant religion in the household (if any)?:
*When is the child available to meet with a mentor? (Indicate all possibilities DAY and time block, ex: SUN Morning, WED Evening):
*What does the child want to be when he/she grows up?:
Child's favorite dessert:
Child's favorite food:
Child's favorite TV show:
Child's favorite movie:
Child's favorite color:
Which after school activities is the child involved with?
Please write in child's activities and hobbies in the next prompt. Examples could include: 
- Attending plays/dramatic productions- Dancing- Drawing/painting- Writing- Computers/video games- Museums- Movies- Reading- Exercise- Basketball- Soccer- Football- Tennis- Cheerleading- Hiking- Shopping- Cooking- Listening to music- Singing/playing musical instruments
Additional interests/hobbies: