2023-24 School Staff Mentee Referral Form
Please complete this form for referring potential students to Mentor Chippewa or any of it's partner programs. 
Once program staff receive a completed referral form, we will contact the student's parent/guardian to complete the necessary new mentee application information. 

If we have further questions for you, we will be sure to reach out. Thank you!

All information in this referral form will be held confidential by the Mentor Chippewa program. 
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Student's Legal First and Last Name *
Student's Preferred Name (if different from above)
Student's Current Grade *
School Attending *
What are you hoping this student gets out of being matched with a mentor?  *
Student's Parent/Guardian's First and Last Name(s) and relationship to student
Parent/Guardian Phone Number(s) *
Parent/Guardian Email Address(es) *
Parent/Guardian is aware their student is being referred to the mentor program and why this program may be beneficial for their student. 

*When parents /guardians are unaware of this referral prior to mentor staff reaching out there is often confusion and it is more likely permission will not be given to participate. 
Please share any other information you feel might be helpful for us to know. 
Who is completing this form? *
Please share your name, title and school
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