Inspire Girls Mentoring Program Application

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About
- Board of Directors
Events
Programs
Newsletter
Contact
Donate

Inspire Girls Mentoring Program
MENTEE REFERRAL INTAKE FORM

We're excited that you're interested in joining the Inspire Girls Mentoring Program!

Please complete the application below so we can learn more about you and your goals. We look forward to supporting your journey toward confidence, leadership, and success.

Participant's Name

Age

Grade

School

Parent/Guardian Name

Address

Parent/Guardian Phone Number

Parent/Guardian Email

Requested by

Position (requested by)

Phone (requested by)

This child is being referred for assistance in the following areas (check all that apply):

Academic Issues Behavioral Issues Delinquency Vocational Training Self-Esteem Study Habits Social Skills Peer Relationships Family Issues Special Needs Attitude Other (specify in comments section below)

Why do you feel this child might benefit from a Mentor?

What particular interests, either in school or out, do you know this child has?

What specific academic subjects, if any, do the child need assistance with?

Academic Performance Level (1 to 10 with 10 being highest)

1 2 3 4 5 6 7 8 9 10

Social Skills

1 2 3 4 5 6 7 8 9 10

Communication Skills

1 2 3 4 5 6 7 8 9 10

Self-Esteem

1 2 3 4 5 6 7 8 9 10

Attitude about School/Education

1 2 3 4 5 6 7 8 9 10

Peer Relations

1 2 3 4 5 6 7 8 9 10

Additional Comments

You Voice • We Listen

Inspire Girls Mentoring Program MENTEE REFERRAL INTAKE FORM

We're excited that you're interested in joining the Inspire Girls Mentoring Program!Please complete the application below so we can learn more about you and your goals. We look forward to supporting your journey toward confidence, leadership, and success.

Inspire Girls Mentoring Program
MENTEE REFERRAL INTAKE FORM

We're excited that you're interested in joining the Inspire Girls Mentoring Program!

Please complete the application below so we can learn more about you and your goals. We look forward to supporting your journey toward confidence, leadership, and success.