School:  __________________________ 

Date of Orientation:  ________________

Student Name:  _____________________ 

Telephone:  _______________________

Grade Level:      ___Freshman    ___Sophomore   ___Junior   ___Senior
 

How did you hear about today's orientation?
       ___Friend   ___Teacher    ___Parent    ___Flyer   ___Other

What is your understanding of mentoring and the information presented?
       ___Not clear - What are your questions?
 

       ___Somewhat clear - What don't you understand?
 

       ___Very clear - Do you have any questions?
 

How could this orientation be improved?
 
 

What is your interest/readiness level for having a mentor and participating in this program?
       ___I am ready (My application will follow)
       ___Somewhat interested
       ___Not interested