Mentee Parent Referral Form (2020-2021 School Year)

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(Form must be filled out by potential mentee parent/guardian.)

CHILL Chariho Mentoring Program

The CHILL Chariho Mentoring Program is focused on providing youth with individual and group mentoring experiences by building positive and supportive personal connections thoughtfully designed to inspire learners to become leaders. CHILL is seeking parent referrals for potential mentees who are incoming 5th through 12th grade students in the Chariho Regional School District for the 2020-2021 school year.

Mentees will be paired with an adult mentor and have access to on- and off- campus opportunities including a YMCA membership, movies, sports, board games, and more! There are mentee openings for current ninth grade students for the 2019-2020 school year!

Upon reviewing your application, the program coordinator will send you (via parent/guardian email) a mentee interest survey (and agreement form) as well as a parent permission form along with additional information.

If you have any questions, please contact katie.kirakosian@chariho.k12.ri.us

Mentee Eligibility Requirements

- An incoming 5th through 12th grade student in the Chariho Regional School District for the 2020-2021 school year

- Demonstrates a desire to participate in the program and abide by all CHILL Program policies and procedures, including completing screening procedures, attending an orientation session and monthly group meetings (~ 1 hour meeting/month), and communicating regularly with the program coordinator

- Agrees, in writing, to a one school year commitment to the program (i.e. September 2020 to June 2021)

- Be able to obtain, in writing, parental/guardian permission and agreement for ongoing support for participation in one year of the program

- Commit to spending a minimum of 3 hours a month with mentor (separate from monthly group meetings)*

- Be willing to communicate with mentor weekly

*After 3 months of participation in the program, mentees should strive to reach 8 hours of mentoring per month (including group activities, 1-on-1 in-person on- and off-campus meetings, and electronic communication)

Student's Name *

Student's current grade of enrollment (2019-2020) *

Current 9th grade students may be paired with a mentor during the current school year

Student's current school *

Chariho Regional Middle School (CMS)

Chariho Regional High School (CHS)

Chariho Alternative Learning Academy (CALA)

Other:

Will the student be attending the same school for the 2020-2021 school year? *

Yes

No, but entering either CMS, CHS, or CALA

Other:

Student's gender

Male

Female

Other:

Clear selection

Referrer (Parent/guardian) Name *

Relationship to student *

Email address *

Phone number

What do you feel the mentee could gain or learn from a mentor and the mentoring experience? *

Do you believe the mentee can commit to all of the program requirements for mentees outlined above? *

This includes: mentee application and interest survey, 1 hour of a mentee orientation, 2 hour mentor/mentee first event, monthly 1-2 hour group meetings, and 3 hours of mentoring per month (e.g., in-person on- and off-campus activities, electronic communication)

Yes

Other:

I understand that the CHILL program is not obligated to provide a reason for their decision in accepting or rejecting the student as a mentee. *

Yes

Other:

Is there any other information you would like to share about the student?

By signing below, you give permission for your child to participate in the CHILL mentee screening process. *

Please type full legal name below

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