***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.