The Puddle Project Mentee Application for Mother

Please complete, submit and save a copy for yourself. (Enter N/A to any field that is required, yet it doesn't apply to you.)

Section 1. Email Address

Section 2. Personal Information

Gender *

Male

Female

Other

N/A

Who lives in the same house with you? (Click all that applies) *

Please add any other household member

How do you prefer to be contacted? *

Cell Phone (Call)

Text Message

Are you currently pregnant? *

Yes

If you are pregnant, what is your due date

If you have already delivered your baby, what is the name of the baby, gender, date of birth and age of your baby.

Clients Needs And Goals

What is your greatest need that you currently have? (check all that apply.) *

If you included OTHER in your needs tell us what else is needed.

What are the names of your doctor(s)? *

Which hospital provides you services? *

You are required to meet with your Mentor at least one hour per month for this program. Please specify the best times that you are available to be Mentored.

Weekdays

Weekends

We are piloting Virtual Mentoring (because of the Pandemic/COVID- 19) when in-person meetings are not possible. Do you have a device that will support this type of meeting? *

Yes

If you have a device that supports Virtual meetings, would you be willing to use this option with your Mentor?

Yes

Can you suggest an alternate place in the community to meet your Mentor if you can not connect during school or after school hours? *

Section 3. Personnel Information regarding the Father of the baby.

Is the Father of the baby interested in being a part of the Mentorship program? *

Yes

Not Sure

Section 4. School and/or Work Information

What year are you in high school? *

What high school are you currently attending? *

If you selected Chicago Public Schools, write the name of your high school below.

Who should we contact at your school? *

Which classes are you currently enrolled it at school? *

What are your special interests, skills, or talents?

Which extracurricular activities are you involved in? *

What is your future career choice?

Are you currently employed? *

Yes

If yes to employment, where are you employed and how many hours do you work each week?

How did you hear about us?

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