Mentor Referral Form
Please take about 5 minutes to fill out this referral form so we can find a mentor for this student. *Remember we are looking for students that may slip through the cracks, are currently not receiving services, and have untapped potential.*
Email address *
Name of Person Referring
Your answer
Student's First & Last Name
Your answer
Student's Current Grade Level
Why do you feel this student might benefit from a mentor?
Your answer
What particular interests does the student exhibit in school?
Your answer
What are the student's strengths and talents?
Your answer
One a scale of 1-5, with 5 being the highest, rate the student's level of overall academic performance.
One a scale of 1-5, with 5 being the highest, rate the student's level of social skills.
One a scale of 1-5, with 5 being the highest, rate the student's level of self-esteem.
One a scale of 1-5, with 5 being the highest, rate the student's level of family support.
One a scale of 1-5, with 5 being the highest, rate the student's level of attitude about school and their education.
Do you have any other comments you would like to make about this student?
Your answer
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