Student I am Recommending ---I Am A Student and I Am Recommending MyselfI Know A Student
Student First Name
Student Last Name
Address
City
State
ZIP Code
Email Address
Phone Number
Gender
Birthday
Current Grade Level
School
Race/Ethnicity
When Are You Available? Write Date Range (example 23 July - 29 July).
List Any Medical, Concerns, Mental Health Conditions or Allergies
Note Any Involvement With Social Services or the Judicial System
Interests, Hobbies, or Activities You Would Enjoy Sharing With a Mentor
What Do You Think Would Be Helpful in Having a Mentor ---Someone to Talk WithEncouragementPersonal GrowthAcademic GuidanceOther
Finish the Sentences Below. No Answer Is Right or Wrong.
A Job or Task That I Really Enjoy Is
A Profession That Interests Me Is
What Is the Most Important Thing That You Think Your Mentor Should Know About You?
Parent/Guardian Name
Parent/Guardian Phone Number
Parent/Guardian Email Address
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