Super sibling Program-Teacher/Parent Referral
Teacher Name
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Parent Name
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Student Name
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Please select *
Student name
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Student’s Grade
Student’s Grade point Average
Why do you recommend this student into the pseudo sibling program?
Your answer
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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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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