Participant Contact Information

Parent/ guardian first and last name(s): *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Alternate Phone

(###)

###

####

Mentee’s first and last name *

First Name

Last Name

Mentee's DOB

MM

DD

YYYY

Mentee's Gender

Male

Female

Other

Mentee Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mentee's Phone

(###)

###

####

IEP

Yes

No

504

Yes

No

Judicial/Juvenile Services:

Yes

No

What do you think would be helpful in having a mentor?

A listening ear

Encouragement

Personal growth

Service

Other

What would you like to accomplish through connecting with a mentor?

Direction

Spiritual Growth

Safe place for me to talk

Positive outlook

Accountability

Other

Describe the personality of a person or people with whom you get along well

Listener

Wise

Deep Thinker

Encourager

Energetic

Imaginative

Athletic

Adventurous

Outgoing

Reserved

Free Spirit

Funny

Sarcastic

Intelligent

Talkative

Organized

Confident

Outspoken

Humble

Other