Student Interest Form - SLSD Mentor Program
Referrer Details (if applicable)
Please fill out this section if you are an adult that is referring a student to the Mentor Program. Otherwise, please skip down to the section titled "Student Details".
Referrer first name
Referrer last name
Referrer phone number
What is the best way to contact you?
What is your relationship to the student? (Example: parent, guardian, counselor, teacher)
Why are you referring this student to the mentor program? How do you hope they will benefit?
What is the best way to connect with the student?
Please contact them directly (via phone, at school, etc.)
Through the referrer (e.g. parent, guardian, counselor, teacher)
If you are referring a student to the Mentor Program, please fill out this section on the student's behalf to the best of your ability. Thank you!
Student's first name
Student's last name
Student's date of birth
What language would you like to speak with your mentor?
Why are you interested in having a mentor?
Have you had a mentor in the past?
Yes, and I want to have another one!
Maybe, I'm not sure
Is there anything else you'd like to share with us?
What is the best way to contact you? Examples: call, text, email, at school, through my parent/guardian. Don't forget to include your contact info! :)
Send me a copy of my responses.
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