Student Interest Form - SLSD Mentor Program
Email address *
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
Your answer
Referrer last name
Your answer
Referrer phone number
Your answer
What is the best way to contact you?
What is your relationship to the student? (Example: parent, guardian, counselor, teacher)
Your answer
Why are you referring this student to the mentor program? How do you hope they will benefit?
Your answer
What is the best way to connect with the student?
Student Details
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 *
Your answer
Student's last name *
Your answer
Student's date of birth
MM
/
DD
/
YYYY
Student's grade
Your answer
Student's school *
Your answer
What language would you like to speak with your mentor? *
Your answer
Why are you interested in having a mentor? *
Your answer
Have you had a mentor in the past?
Is there anything else you'd like to share with us?
Your answer
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! :)
Your answer
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