Student Questionnaire
Please Print in Ink 	Today’s Date:	
Name______________________________Address	
City______________________Zip__________Home Phone	
Ethnicity_______________Male_____Female_____Grade Level	
Languages Spoken	
School__________________________________Date of Birth	
Names of Parent(s) or Guardian	
Day Phone_______________________________Home Phone	
Please answer the following questions fully and honestly. There are no right or wrong answers. The purpose of gathering this information is to have a basis for matching you with a mentor. 
List the classes you are taking this year:	
In which classes do you do well?	
With which classes do you feel you need help?	
Do you get assistance with your homework? If yes, by whom?	
How well are you doing in school?	
Please give the name of a teacher whose class you have attended and who knows you well	
Please give the name of your counselor	
What are the school extracurricular activities in which you participate?	
Have you thought about your education beyond high school? Yes or No. If yes, please explain:	
	
Do you currently work outside of school? Yes or No. If yes, please give employer’s name, address and phone number:	
Hours of employment:	
In which activities do you participate during your free time (music, reading, sports, art)?	
	
What do other people tell you that you are good at?	
What do you think you are good at?	
What do you like most about yourself?	
Who do you look up to or admire?	
Please answer yes or no to the following questions. Please mark the way you feel inside.
I am smart	yes	no
It is hard for me to make friends	yes	no
I get worried when we have tests in school	yes	no
I am well behaved	yes	no
I am slow in finishing my work	yes	no
I wish I were different	yes	no
I can be trusted	yes	no
I lose my temper easily	yes	no
I am sick a lot	yes	no
I am attractive	yes	no
I am good in my school work	yes	no
I often get into trouble	yes	no
I am easy to get along with	yes	no
I am often late to school	yes	no
I like being alone	yes	no
As a willing participant in the Mentor Project, I commit to working with my mentor through the duration of the program, attending all scheduled meetings with my mentor, and communicating weekly with my mentor. Emergencies happen to all of us. Should I be unable to keep a meeting with my mentor, I shall call in advance to reschedule. I agree to develop personal goals with my mentor and to be open to coaching and feedback from my mentor. In the event that I wish to discontinue my match for any reason, I will first notify the Mentor Coordinator and discuss this before discontinuing.
			
Student’s Signature                                                                                     Date