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Mentor Commitment Form 2011-2012
Thank you for committing to ensuring KIPP Renaissance students stay on the path to and through college! Please fill out each part of the survey below. We will be reaching out to you following your completion of the survey.
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Contact Information
Please provide us with the most up-to-date information so that we may contact you regarding upcoming event details. Please make sure to let us know what information you would like to have available to your mentee.
1) Full Name
*
First and Last
Your answer
2) Company Name
Your answer
3) Primary Phone Number
*
(xxx) xxx - xxxx
Your answer
Secondary Phone Number
(xxx) xxx - xxxx
Your answer
4) Email Address
*
Your answer
5) Mailing Address
Your answer
City, State
Your answer
Zip Code
Your answer
6) Undergraduate University
Your answer
Undergraduate Major(s)
Your answer
7) Graduate University
If applicable
Your answer
Graduate Degree (s)
If applicable
Your answer
8) What contact information would you be willing for us to share with your mentee?
*
Please check all that apply.
Email
Primary Phone Number
Secondary Phone Number
Mailing Address
Required
Additional Comments
9) Please include the names and contact information of others you think might be interested in participating in this mentoring program.
Your answer
10) If you had a mentee from Renaissance last year, please write their name in the space below.
Your answer
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