Liaison Mentorship Program Interest Form

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Name *

Local Education Agency *

Job Title *

Email *

Phone Number *

# of years of experience as a Homeless Liaison *

I am interested in being a... *

Mentee (1 year or less of experience)

Mentor (2 years or more of experience)

I would prefer to mentor/mentee a liaison from (check all that apply)

Same county

Brick and mortar school district

Charter school

Cyber charter school

Intermediate Unit

Other:

Is there anything else you'd like us to know to help with matching?

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This form was created inside of Berks County Intermediate Unit.