Mentor Name

Student Name

Teacher Name

Grade level     School Name

Days of Week Mentored

Time Slot Mentored:  From  To

How did you mentor? (Choose one) One on One    Team (two adults shared mentor responsibility)

On average, how much time did you spend with your mentee?  (Please choose one)

1/2 Hour        45 Minutes        1 Hour        Other

What activities did you regularly do with your student? (Please choose one)

School work            Socialization/Life Skills              Behavior              Other

What amount of improvement did you see in your student’s overall work? (Please choose one)

 No improvement     Some improvement      Great improvement     Don’t Know

Total Number of Days Mentoring?Total Number of Hours Mentoring?

Yes, I plan to return as a Fountain Hills Mentor for the next school year.
No, I am unable to return as a Fountain Hills Mentor for the next school year.

Signature_________________________________________  Date:____________________

Please print your completed evaluation form, sign and date it and mail to:
Fountain Hills Mentoring Council
C/O McDowell Mountain School
14825 N Fayette Dr., Fountain Hills, Az. 85268