Parent/Guardian Questionnaire

Dear Parent/Guardian:
You play a very important part in the success of our mentoring program. Please complete the following questions. This information will help us to properly match your child with a mentor. Only same gender matches are considered.
Please Print in Ink
Name of Student 	
Name of Parent/Guardian 	
Place of Employment 	
Street Address 	
City _______________________________________ Zip Code 	
Home Phone _________________________ Work Phone 	
Describe how your child is doing in school 	
Describe your child’s personality (outgoing, introverted, shy, friendly, confident, stubborn, etc.) 	
Describe the type of mentor that would best suit your child 	
Do you have a concern regarding the ethnicity/gender of your child’s mentor? 	
If yes, please explain 	
What do you hope your child will gain from having a mentor? 	
Do you have any concerns about your child having a mentor? 	
If yes, please explain 	
Are there any factors that would prevent your child from participating in this program (transportation, babysitting, employment or any other responsibilities)?	
Additional comments: