| D.A.A.S MENTOR PLACEMENT FORM |
Applicant Information
Please copy and post to Chair, Youth Development Committee
Last Name: ____________________ Telephone Number: _______________________________
First Name: ____________________ E-mail Address: _______________________________
Name of Parent or
Legal Guardian: _________________________________________________
Mailing Address: _________________________________
_________________________________
_________________________________
Name of
School/College: _____________________ Area of Study Interest: ______________
Form/Class: _______________ Areas where assistance is most needed:
_____________________
_____________________
Name of Principal: _______________________________________
Name: ______________________ Job
Title: ___________________________
Mailing Address: ________________________ Telephone Number/s: _______________
________________________ E-mail Address: _____________________
With 1 Being The Highest Rate
Yourself
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2 |
3 |
4 |
5 |
n/a |
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Understands the Mentoring Program |
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Ready to Begin |
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Will Recruit Someone Else |
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Community Development Involvement |
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Commitment to the Program |
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Academics
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1 |
2 |
3 |
4 |
5 |
n/a |
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Area of Studies |
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Interest in Reading |
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Extra Curricular Activities |
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Time Management Skills |
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Interest In Advance Learning |
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