First Name: Middle Initial: Last Name:

Date of Birth:    Gender: Male    Female

Ethnic Category (Please check the box that describes your race/ethnicity):

American Indian/Alaskan Native    Black    Hispanic/Latino    White

Asian    Filipino    Pacific Islander    Other/Specify:

Physical Address: City: State: Zip Code:  

Mailing Address:  City: State: Zip Code:

Home Telephone Number:                 Email Address:

Father/Guardian Name:    Occupation:    Work Number:

Mother/Guardian Name:    Occupation:    Work Number:

Emergency Contact:    Relationship:   

Home Phone:    Work Number:

In addition to English, list any other languages you speak (Check all that apply):

Cantonese    Mien    Russian    Tagalog

Hmong    Romanian    Spanish    Vietnamese    Other: 

School Information

Name of School:    Grade Level:    Counselor Name:

List the classes you are taking this year:

Class:                                Teacher:

What are your favorite subjects in school (Check all that apply):

English    Drama    Social Studies/History    Science    Art

Math    PE    Home Economics    Computers    Other:

What subjects do you feel you need most help with (Check all that apply):

English    Drama    Social Studies/History    Science    Art

Math    PE    Home Economics    Computers    Other:

What was your GPA last semester?

How many days of school did you miss last semester?     How many times were you late to class last semester?

Your Interests

Please check your interests or hobbies:

Arts and Crafts    Computers    Reading

Clubs    Performing Arts    Sports/Athletics    Other:

Do you participate in any extracurricular activities outside of school (i.e., boy/girl scouts, youth programs, etc.)?

If yes, explain:

What is your career goal or what types of careers interest you?

What would you like to learn more about or become better at with the help of a mentor?

Do you plan on attending college after you graduate?    Yes    No

Favorites

What is your favorite:

    Food:    Color:    Book:    Movie:

    Music Group:    Song:    Person:

Match Information

What day of the week are you available to meet with your mentor? (Check all that apply):

Monday    Tuesday    Wednesday    Thursday    Friday    Saturday    Sunday

What is the best time for you to meet with your mentor? (Check all that apply):

Mornings    Afternoons    Evenings    Weekends

Check the school-related activities you would like to do with a mentor (Check all that apply):

Accounting    Computer Projects    Holiday Events    Music Programs    Art Projects    Field Trips

Reading    Improve Study Habits    College Preparation    Foreign Language    Job Shadow

Science Projects    Career Development    Homework Assistance    Mathematics    Sports

Write down the three words that best describe you?

Please read before signing: The Franklin Center of Beaver County appreciates your interest in becoming a student mentee with our mentor program.

As a willing participant, I commit to working with my mentor through the duration of the school year, attend all scheduled meetings, and communicate on a weekly basis. Should I be unable to keep a meeting with my mentor, I will call in advance to reschedule. I agree to develop personal and academic goals with my mentor and to be open to feedback. In the event that I wish to discontinue for any reason, I will notify the Mentor Program Coordinator and discuss this before continuing.

Please attach: Teacher Recommendation Form

                         Student Activity Parent Permission Form

Student Signature:__________________________

Date:______________________