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Academic Mentoring Program | Student Sign Up Form (SY23-24) 
Thank you for your interest in the Academic Mentoring program! Our goal is to connect you with a caring mentor who will support you throughout the school year. This could be by providing homework help, 1:1 tutoring, or just being there to listen and connect you to other resources. By completing this form, you are letting us know it's OK to reach out to your parent/caregiver to get permission for you to participate in this program if you are under 18. We look forward to supporting you on your road to success!
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First Name *
Last Name *
Student ID # *
If you don't know your ID #, please enter 000000 and we'll help find it. 
What grade will you enter in September 2023? *
School Name *
Student Email Address *
Student Phone
Have you worked with an academic mentor before? *
If you have previously worked with an academic mentor, what is their name?
Give us a short biography about yourself. What's important for us to know about you? How would someone who knows you well describe you? What are some of your interests or hobbies? *
How do you believe participating in the program would contribute to your academic development and overall well being? *
Which mentorship model do you prefer? *
I identify as... *
Do any of these describe you? *
Yes
No
Prefer not to share
I have experienced homelessness or housing insecurity
I have been involved with DCF
I have an Individualized Education Program (IEP)
I have experienced food insecurity or other financial hardships
English is not my native language
I have experienced difficulty attending school consistently
I am on-track academically
I identify as a student of color
I identify as LGBTQ+
Which mentorship areas are you most interested in? *
Most Interested
Interested
Not Interested
Academic-focus
Relationship-focus
Achieving Goals
College and Career Exploration
Community Involvement
Leadership
What subjects would you like to focus on with your mentor? *
Required
Which mentor characteristics are most important to you? *
Most Important
Important
Not Important
Similar background (racial, ethnic, cultural, or linguistic)
Language requirements
Geographic location/mobility
Availability/schedule
Shared or compatible interests
Life experience
Shared values
Temperament
Personality traits
Mentoring experience
Do you have a gender preference for your mentor? If so, identify which gender you would prefer to be matched with.
Finish this Sentence: "My ideal mentor would be..."
Parent/Guardian First Name *
Parent/Guardian Last Name
 *
Please provide an email address for us to contact your parent/guardian. If they do not have email, please provide another way to contact them (e.g., phone or mailing address). *
By checking the box below, I understand someone from the Academic Mentoring Program will contact my parent/guardian to get permission for me to participate. *
Required
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