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. Please note, there is a $20 annual registration/participation fee required by all mentee participants in the Essie's Girls Inc. Mentoring Program.
Email *
Student Name *
Parent/Guardian Name *
Relationship to Youth *
Address *
Home Phone *
Work Phone
Student Date of Birth *
Clear selection
Name of School
Why do you/your child want to participate in a mentoring program?
Briefly describe your expectations for Essie’s Girls Mentoring Program?
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.
Describe your child’s school performance including grades, homework, attendance, behaviors,etc.
Does your child have friends? Please describe her friendships.
Is your child currently having any problems either at home or school?
Has your child experienced any traumatic events (i.e., death in the family abuse, divorce)? If yes,please provide details.
Can you provide any additional background information that may be helpful to Essie’s Girls inmatching your daughter with an appropriate mentor?
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