Mentee Application

If you are interested in being contacted by a staff mentor from ATLAS,
please fill out the information below.

IMPORTANT: This information is strictly confidential and will not be
viewed by anyone other than a staff mentor at ATLAS.

• Contact Information:

  Name
  Street Address
  Address (cont.)
  City
  State/Province
  Zip/Postal Code
  Country
  Work Phone
  Home Phone
  E-mail
  Date of Birth
  Sex	Male Female

• Marital Status:  Never Married Married Separated Widowed Divorced

• In which areas of struggle do you need assistance? Choose
  all that apply:

• Spiritual issues  Emotionally    Finances         
  Death             Addiction(s)   Physical
  Broken Marriage   Depression     Other

  
  
• Do you regularly attend a church: Yes No
  
  
• If yes, which church: 
  
  
• Tell us a little bit about your situation:

• How did you hear about ATLAS? Choose all that apply:

• Friend      Pastor    TV Advertisement         
  Brochure    Parent    Church
  Work        Other        

• When would you like to be contacted:

  -- mm/dd/yy