Super sibling Program-Teacher/Parent Referral
Teacher Name
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Parent Name
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Student Name
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Student name
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Date
MM
/
DD
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YYYY
Student’s Grade
Student’s Grade point Average
Why do you recommend this student into the pseudo sibling program?
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Do you prefer this student to be in the Academic or behavioral Program?
6. Does this student show Behavioral Issues?
List Behavioral Issues below
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Requirements
Mentors (Grades 9 – 12):
• Must apply to be a mentor and be accepted
• Could be focused on academic, social, or behavioral
• To be academic mentor, must have at least a 3.0 GPA
• To be social mentor, must be outgoing and fun-loving in appropriate ways
• Must exhibit positive, ethical, Christ-like behavior
• Will only be assigned to mentees of same gender
• Must agree to participate with mentee outside of school monthly (may be school sponsored activity or otherwise)
• May be approved to work with up to two pseudo-siblings
• May be removed from the program for failing to attempt to satisfy pseudo-sibling needs and/or for not following program procedures
• Program would qualify for volunteer hours toward Bright Futures requirements
• Must participate in training program before being approved
• Must not discipline pseudo-siblings other than time out

Mentees (Grades 6– 8):
• May be recommended by teacher, staff, parents, or self
• May need assistance in academic, social, behavioral areas, or may just want companionship and a positive role model
• May be removed from the program for being a behavior problem with their pseudo-sibling
• Must be willing to receive input and guidance from their pseudo-sibling and maintain a respectful relationship

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