ESTATE BOVONI – TUTU HI-RISE WEED AND SEED 
                                         GROVE PLACE WEED AND SEED  
Tel# 340-776-1525 STT  
340-201-9097 STX 
        YOUTH MENTOR APPLICATION 
DRUG   EDUCATION   FOR   YOUTH 
                                                                                                        Coordinator Use Only 
 Date Received: __________  
             Application #: ___________ 
 
Please type or print legibly – To be completed by Parent  or Guardian 
 
Mentor’s Name: __________________________________________ Age _____ DOB:  ___/ ___/_____ 
 
Mentor’s Address:  _____________________________________________________________________ 
 
Mentor’s Email Address: _________________________________________________________________ 
 
Name of Mentor’s School: _____ __________________________________________________________ 
Last Grade attended________________________ Promoted ________________ Retained ____________ 
Father’s Name:  _______________________________________________________________________ 
Father’s Address: ___ ___________________________________________________________________ 
Work Phone: (    )    _______________   Home Phone: (   ) ______________________________________ 
Email Address: ________________________________________________________________________ 
 
Mother’s Name: ___ ____________________________________________________________________ 
 
Mother’s Address: _____ ________________________________________________________________ 
Mother’s Work Phone: (   ) __________ Home Phone: (____) __________________________________ 
Email Address: ________________________________________________________________________ 
 
Legal Guardian’s Name: _____ ____________________________________________________________ 
Legal Guardian’s Address: _____.__________________________________________________________ 
 
Guardians Work Phone: (____) _______________________________ Home Phone: (_____) __________ 
Email Address:  ________________________________________________________________________ 
 
Previous DEFY Attendance                         Yes _______ No ________ Where ______________________ 
 
By my signature, I agree to make the youth applicant available for the Phase I Summer Leadership Camp and the Phase II 
School - Year Mentoring Component.  I also agree to participate in any and all program measures of effectiveness studies, 
surveys, and questionnaires to further improve the quality of the Program. 
 
Signature ____________________________________                 Date   ___________________________