Mentee Referral Application

LOVING ARMS MENTOR PROGRAM

Creating Vision Through Mentoring

Mentoree Referral Application

(For Use by School and Other Community Agency Staff )


Contact and Mentoree Information
Youth Name:
Age:
Grade:
School:
Requested by :
Position:
Email:
Phone:
Care Givers Name:
Phone
The child is being referred for assistance in the following areas

(check all that apply):


 Academic Issues Behavioral Issues Delinquency Vocational Training Self-Esteem Study Habits Social Skills Peer Relationships Family Issues Special Needs Attitude

Other (specify) :

Why do you feel this youth might benefit from a mentor?
What particular interests, either in school or out, do you know of that the child has?
What strategies/learning models might be effective for a mentor working with this youth?
On a scale of 1–10 (10 being highest) rate the student’s level of:

Academic performance

Social skills

Self-esteem

Family support

Communication skills

Attitude about school/education

Peer relations

With what specific subjects, if any, does the student need assistance?

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