High School Student Peer to Peer Mentor Application

The information provided in this application will help to match you with a student and will be kept confidential.  PLEASE PRINT ALL INFORMATION.

Name: ____________________________________________________________________________________

Address: __________________________________________________________________________________

                Street                        City                         State                Zip

Home Phone: ____________________________ Cell Phone: ______________________________

E-mail Address: __________________________________________________________________________

DOB: _______________ Age: _____________ Sex: ________________

School Information

School Name: ___________________________________________________________________________

Grade: ______________ GPA: ________________

List the extracurricular activities you are involved with (sports, NHS, drama, Science

Olympiad, cheerleading, etc.): ___________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

 When do these activities meet/practice: _____________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

 Have you worked with children before? Please explain. ________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

______________________________________________________

 At which schools are you interested in being a mentor? 1) _______________________________

2) ____________________________________ 3) ____________________________________

References

Please list the names, addresses and daytime telephone numbers of three (3) Adults (not in

your immediate family) who have known you for at least three (3) years.

1) Name: ________________________________________________________________________________

Phone Number: __________________________________________________________________________

E-mail Address: __________________________________________________________________________

Relationship: _____________________ Years Known: ____________________________

2) Name: ________________________________________________________________________________

Phone Number: __________________________________________________________________________

E-mail Address: __________________________________________________________________________

Relationship: _____________________ Years Known: ____________________________

3) Name: ________________________________________________________________________________

Phone Number: __________________________________________________________________________

E-mail Address: __________________________________________________________________________

Relationship: ______________________ Years Known: ____________________________

 

Other Information

 Do you have transportation: Yes: _______ No: ________

What days and times are you available to mentor:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

What grade level do you prefer? (Circle all that apply)

Kindergarten           1                    2                     3                     4                     5

 

In Case of an emergency please contact:

Name: ______________________________ Phone: ________________________________

Please list any languages you speak other than English: ________________________

______________________________________________________________________________

Have you ever been arrested, or involved with the police or courts? If yes, please explain:

__________________________________________________________________________________________

__________________________________________________________________________________________

Training

Please see your site mentor coordinator about scheduling a mentor training.

Training Date: _________________


Mentor Agreement

As a site-based Mentor, I agree to the following basic requirements:

We appreciate your interest in becoming a mentor to a child. By submitting this application, you agree to the terms of the mentor agreement and attest to the truthfulness of all information listed on this application.

Please sign your name below to verify that you agree with the mentor agreement:

 

Mentor Signature: __________________________ Date: ___________________________

125 Avery Street  Garner.NC 27540

Info@phatkidsmentoring.org    www.phatkidsmentoring.org