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Student Referral for Mentor Program
Fill out this form to refer a student in the White County School System to take part in our White County Family Connection Mentor Program. Once a mentor is available, we will submit a permission form to the student's guardian before meeting with a mentor.
For questions, reach out to Haley Hobson, Mentor Program Coordinator, 706-969-5066,
haley.hobson@white.k12.ga.us
.
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* Indicates required question
Name of Referrer
*
Your answer
Your Relationship to Student
*
Your answer
Phone Number or Email of Referrer
*
Your answer
Student Name
*
Your answer
Student School and Grade
Your answer
Reason for Referral. Please include any relevant information, such as behavior issues, family situation, attendance issues, social interaction issues, impairments, etc.
*
Your answer
Ideal Mentor Pairing (check all that apply)
*
Male
Female
Young Adult
Middle-Aged Adult
Senior Adult
Other:
Required
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