_________ERHS REFERRAL FORM________
Imara Roose Inc. is a holistic, inclusive, and transformative mentoring program that assists high school girls with actualizing and maximizing their greatness—personally, academically, and professionally—by empowering them with the knowledge, skills, and social capital necessary to break through systemic barriers to equitable access and opportunity.

Imara Roose mentees are girls (9th-12th grade) who attend Eleanor Roosevelt High School (ERHS) in Greenbelt, MD.These individuals seek motivation, inspiration, and support that has the power to change their trajectory.

Weekly meetings take place at ERHS Mondays and Thursdays 3:30PM-4:45PM. Monday meetings (i.e., Mentor Mondays) are mandatory for all mentees (i.e., 9th-12th grade) and Thursday meetings (i.e., College & Career Readiness) are only mandatory for 10th-12th grade mentees, BUT all mentees are encouraged to attend. Monthly events (i.e., community services, fundraisers, socials, etc.) generally take place on Saturdays/Sundays. Additionally, mentors meet with their mentee, one-on-one, at least once per month.

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ERHS administrators, counselors, and teachers are welcome to submit this form as a means to refer students for the program. We will email the application to the student and their legal guardian.

Click here for the application to be completed by students: https://forms.gle/9JhhZ3RfeQnPQmPB6

Click here for the application to be completed by parents: https://forms.gle/SgC2NmJ8uVw6BcZw7

Applications for the 2020-21 school year will be reviewed on a rolling basis.

For more information, visit www.ImaraRoose.org or email Contact.ImaraRoose@gmail.com with “Referral” in the subject line.

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ERHS STAFF
The section below requires your information, NOT the information of the student you are referring:
FIRST NAME *
LAST NAME *
EMAIL ADDRESS *
PGCPS EMAIL ADDRESS
ROLE *
SHORT ANSWER
Please provide as much detail as possible so we can do our best to assist this student:
QUESTION #1: *
Why are you referring this student/what do you hope they will gain from Imara Roose?
QUESTION #2 *
What type of mentor do you believe is best suited for this student? (i.e., characteristics, interests, personality, etc.)?
QUESTION #3
Is there any additional information you’d like to share to assist us in better supporting this student?
STUDENT
The section below requests the information of the student you are referring:
FIRST NAME *
LAST NAME *
CELL PHONE *
(xxx-xxx-xxxx)
EMAIL ADDRESS *
GMAIL ADDRESS PREFERRED
HOME ADDRESS *
(STREET, CITY, STATE, ZIP CODE)
BIRTHDAY *
(MONTH/DAY/YEAR)
CLASS *
LEGAL GUARDIAN
Please specify the contact information of the student’s legal guardian:
RELATIONSHIP
If you selected an option that indicates "specify," please detail your answer below:
FIRST NAME
LAST NAME
CELL PHONE
(xxx-xxx-xxxx)
EMAIL ADDRESS
GMAIL PREFERRED
OTHER
HOW’D YOU HEAR ABOUT IMARA ROOSE? *
If you selected an option that indicates "specify" please detail your answer below:
ADDITIONAL INFORMATION?
Is there any additional information you'd like to share?
Submit
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