Part 1 - To be completed by the student.  Your parent must also complete Part 2 at
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Email *
Student Name: *
Student Phone Number: *
Student Address: *
Date of Birth: *
What grade and school are you currently in? *
How did you hear about our program?
What are your hobbies?
What are your interests?
Please explain any health problems, which may require special accommodations or assistance, including dietary requirements or food allergies:
Why would you like to have a mentor?
Please describe any particular preferences you may have regarding your mentor:
What do you hope to gain from this experience?
Please describe any traits or talents you possess, which you would like your mentor to know about:
Describe questions or concerns you have about meeting with a mentor:
Parent Name: *
Parent Phone Number: *
Parent Email: *
By typing my name below, I acknowledge that I agree with the following statement: I would like to be matched with a mentor, with whom I will meet weekly during the academic year. I understand that I must follow all school rules and regulations when meeting with my mentor, including signing in and out and being in the designated meeting place at the prearranged time. TYPE YOUR FULL NAME BELOW TO SIGN THIS FORM. *
A copy of your responses will be emailed to the address you provided.
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