***2017-2018 FHMP Mentor Profile Application

 

Name:   _________________________________________________________________________________

 

Arizona Phone Number: _______________________ Out-of-State Phone Number: ______________________

 

Email Address: _________________________________________________________________________

 

_____ Yes, I would like to receive mentoring info by email.

_____ No, I would not like to receive mentoring info by email.

 

Arizona Address: _____________________________________________________________________________

Out-of-State Address: _________________________________________________________________________

 

(Please check)

  1. Mentored last year at: __McDowell Mountain __ Four Peaks __ Middle School __ High School __ New Mentor

(Please circle)

  1. Prefer to Mentor in:    K   1st  2nd     3rd     4th     5th     6th    7th    8th     High School   Any Grade

 

  1. I would be willing to mentor a second student either before or after the student I am assigned.   ____Yes ____No

 

  1. I would like to mentor with the same teacher I had this year. ____ Yes ____ No

 

If yes, please provide teacher’s name. ______________________________________________________

 

  1. I would like to mentor with the same student I had this year _____ Yes ______ No

 

If yes, please provide student’s full name and current grade. ________________________________________________________

 

  1. Date you are available to start mentoring (ex. after Sept. 1): _________________________________________________________

 

  1. Day(s) of week and time(s) you are available to mentor: ______________________________________________________________
  2. Besides English, list other languages spoken. _________________________________________________________________________

 

  1. Work   experience and number of years in occupation:   _______________________________________________________________
  2. Hobbies, family background, academic strengths, special talents or experiences that you would like to share with a student:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Additional Comments and Requests: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

  • I swear or affirm that all of the information provided on this Mentor Profile is true and correct.
  • I give my consent to the Fountain Hills Mentor Program to conduct a complete background check on me.
  • I have received and read the Fountain Hills Mentor Program Resource guide and I agree to the terms, conditions, policies and procedures contained therein.
  • By signing below I affirm and consent to all of the above

_______________________________________________________________                _________________

 Applicant for Mentor Signature                                                       Date

 

*** Please return this form to the school’s office
or mail to Jeannie Ryan, 15345 E. Sundown Drive, Fountain Hills, AZ 85268.

 Created for The Fountain Hills Mentor Program by SA Enterprises 480-251-2404 ©2017