Student Sign Up Form
Thank you for your interest in obtaining a mentor for your precious young lady. Please
complete the following and someone will contact you within 48 hours.
Angus *
Your answer
Parent/Guardian Name *
Your answer
Relationship to Youth *
Address *
Your answer
Home Phone *
Your answer
Work Phone
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Ethnicity
Name of School
Your answer
Grade
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Why do you/your child want to participate in a mentoring program?
Your answer
Briefly describe your expectations for Essie’s Girls Mentoring Program?
Your answer
Is your child available to meet with a mentor four hours per month and have contact at leastonce a week for a minimum of one school year? Please explain any particular scheduling issues.
Your answer
Describe your child’s school performance including grades, homework, attendance, behaviors,etc.
Your answer
Does your child have friends? Please describe her friendships.
Your answer
Is your child currently having any problems either at home or school?
Your answer
Has your child experienced any traumatic events (i.e., death in the family abuse, divorce)? If yes,please provide details.
Your answer
Can you provide any additional background information that may be helpful to Essie’s Girls inmatching your daughter with an appropriate mentor?
Your answer
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