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Mentee Referral Form
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* Indicates required question
Youth name:
*
Your answer
Age:
*
Your answer
Grade:
Your answer
Requested by:
*
Your answer
Position:
*
Your answer
Phone number:
*
Your answer
The child is being referred for assistance in the following areas (check all that apply):
*
Academic Issues
Self-Esteem
Family Issues
Behavioral Issues
Study Habits
Special Needs
Delinquency
Social Skills
Attitude
Vocational Training
Peer Relationships
Other:
Required
Why do you feel this youth might benefit from a mentor?
*
Your answer
What particular interests, either in or out of school, do you know of that the child has?
*
Your answer
What strategies/learning models might be effective for a mentor working with this youth?
*
Your answer
On a scale from 1-10 (10 being the highest) rate the student's level of:
Option 1
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