***2017-2018 FHMP Mentor Profile Application
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: _________________________________________________________________________
- Mentored last year at: __McDowell Mountain __ Four Peaks __ Middle School __ High School __ New Mentor
- Prefer to Mentor in: K 1st 2nd 3rd 4th 5th 6th 7th 8th High School Any Grade
- I would be willing to mentor a second student either before or after the student I am assigned. ____Yes ____No
- I would like to mentor with the same teacher I had this year. ____ Yes ____ No
If yes, please provide teacher’s name. ______________________________________________________
- 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. ________________________________________________________
- Date you are available to start mentoring (ex. after Sept. 1): _________________________________________________________
- Day(s) of week and time(s) you are available to mentor: ______________________________________________________________
- Besides English, list other languages spoken. _________________________________________________________________________
- Work experience and number of years in occupation: _______________________________________________________________
- 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.