LATM e-Works > LATM Registration

Application

LATM E-Works Mentoring Application
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Username/Nombre de usuario
Password/Contraseña

Password

Confirm Password
I would like to participate as a/Me gustaría participar como
Prefix
First Name/Nombre
Middle Name/Segundo Nombre
Last Name/Apellido
Parent/Guardian First and Last Name/Nombre del padre o gurdian
Email/Correo electronico
Home Street Address/Dirección
City/Ciudad
State/Estado
Zip Code/Código postal
Country/Pais
Home phone/Telefono de casa
Cell/Mobile/Celular
Work phone/Teléfono del trabajo
Work phone extension/Extensión
What is your preferred method of communication?/Comunicación preferida
Date of Birth for the participant in the program/Fecha de nacimiento del participante en el programa
Gender/Género
Please enter your self-described gender here./Por favor ingrese su género autodescrito aquí
Family Household Income/Ingreso familiar del hogar
Ethnicity/Etnia
If you select other for ethnicity please share here/Si selecciona otro por origen étnico, por favor comparta aquí.
Parent/Guardian or Mentors, what is your highest level of Education?/Padre / Guardian ¿cuál es su nivel más alto de educación?
Please send potential mentors our way. Do you have a friend or colleague that would make a good mentor? Please provide complete name, phone number and email address.
Primary Emergency Contact Name/Contacto de emergencia
Relationship to Primary Emergency Contact/Relación con el contacto principal de emergencia
Primary Emergency Contact Home Phone/Telefono de casa
Primary Emergency Contact Mobile Phone/Celular
Primary Emergency Contact Work Phone/Trabajo
Primary Emergency Contact Work Phone Ext
Primary Emergency Contact Email/Correo electronico del contacto de emergencia
School Name/Nombre de Escuela
Grade Level/Nivel de grado
Have you participated in the e-Works/Teamworks mentoring program before?/¿Ha participado anteriormente en el programa de e-Works / Teamworks?
What grade level did you participate in?/Qué nivel de grado participó?
Are you a returning mentor?
How many years have you participated?
If you have participated more than 3 years, how many?
What type of mentor are you?
If you are a mentor from one of our corporate or college partnerships, which one?
Besides mentoring, in what other capacities would you like to work with LATM?
Medical Conditions?/¿Condiciones médicas?
Please describe medical conditions here./Describa
Medical Conditions Allergies/Alergias
Please describe or list allergies here./Describa
Does your child have any academic, personal, skill or behavior challenges?/¿Tiene el estudiante algún desafío académico, personal, de habilidades o de comportamiento?
Please describe challenges/Describa
Is your child currently in counseling?/¿Está el estudiante en terapia?
Please share the purpose of the counseling./Comparta el propósito de la consejería.
Name of Medical Provider/Proveedor medico
Medical Policy Number/Número de póliza
What is your household make up?/¿Cuál es la composición de su hogar?
Student's Grades/Calificaciones del estudiante
Is your child in receipt of any ancillary services?/¿Su estudiante recibe servicios auxiliares?
Please describe the ancillary services./Describa
Has your child experienced any traumatic events ( i.e.,death in the family, divorce, etc.)?/¿El estudiante ha experimentado algún evento traumático (es decir, muerte en la familia, divorcio, etc.)?
If yes, to above please provide details./Describa
Does your child attend any other after school program?/Asiste a algún otro programa extracurricular?
Name of other after-school program(s)/Nombre de otro programa
What is the scheduled attendance of the after-school program?/Horario del otro programa
Does your child shy away from taking the lead and prefers being a member of the team?/¿Su estudiante evita tomar la iniciativa y prefiere ser miembro del equipo?
Does your child get along with all students and likes to help others?¿Su estudiante se lleva bien con todos los estudiantes y le gusta ayudar a los demás?
Does your child exercise good sportsmanship when playing games?/¿Su estudiante ejerce un buen espíritu deportivo cuando juega?
1st Choice Day
1st Choice Time
2nd Choice Day
2nd Choice Time
3rd Choice Day
3rd Choice Time
Mentors Release and Waiver of Liability
Click to review the Mentors Release and Waiver of Liability

The form will display in an additional window in your browser. Once you have completed reviewing

the form please come back to this page to complete and submit your application.
Please read and type YES with your acceptance of the Mentor Release and Waiver of Liability.
Yes|yes|YES
When you select submit form you will have a few more steps to complete./Cuando termine el formulario, tendrá que completar unos pasos más.
1. Select the role of Mentor or Student Applicant. / Seleccione el rol de mentor o estudiante solicitante.
2. Once you have selected your role you will be sent a confirmation email. If you are a parent/guardian registering a student, please make sure to fill out the Parent/Guardian Release form that is attached to that email./Una vez que haya seleccionado su función, se le enviará un correo electrónico de confirmación. Si usted es un padre / guardian que está registrando a un estudiante, asegúrese de completar el formulario de autorización que se adjunta a ese correo electrónico.

LATM Registration

Application

LATM E-Works Mentoring Application

Mentors Release and Waiver of Liability