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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:     _______________________________________

 

 

Mentor Information

 

Name: ______________________                                        Job Title:        ___________________________

 

Mailing Address:       ________________________            Telephone Number/s:            _______________

 

                                    ________________________            E-mail Address:         _____________________

 

With 1 Being The Highest Rate Yourself

1

2

3

4

5

n/a

Understands the Mentoring Program



 

Ready to Begin

 

Will Recruit Someone Else

 

Community Development Involvement

 

Commitment to the Program

 

 

 

Academics

1

2

3

4

5

n/a

Area of Studies

 

Interest in Reading

 

Extra Curricular Activities

 

Time Management Skills

 

Interest In Advance Learning