Confidential
Student
Information
Please complete the following information which
will enable us to match you with a mentor: |
Name: ______________________________________
Male: ____ Female: ____
Age: ____ Grade: ____ Shirt Size:
____
Address: ________________________________________________________
Telephone: ___________________
Driver License Number: _________________
Parent/Guardian Name: _______________________
Work Phone: ____________
Parent/Guardian Name: _______________________
Work Phone: ____________
Areas of Interest:
1. ___________________ 2. __________________
3. ____________________
Hobbies: _____________________________________________________________
Other Interests: _______________________________________________________
Please add any additional information that will help us match you with
a mentor:
|