Date: _____/____/_____

Name: __________________________________________________________

Home Address: _________________________________________________________________________

City: _________________________________________ State: _____________________ Zip: __________

Home Phone: _________-_________________ Cell Phone: ________-________________

Work Phone: _________-_________________ Employer: __________________________

E-mail Address: ____________________@_____________________________________________________

Male/Female: ________ Ethnicity: ______________

References:

1. Name: ____________________________________ Phone (______) _______________-_______________

2. Name: ____________________________________ Phone (______) _______________-_______________

3. Name: ____________________________________ Phone (______) _______________-_______________

Hobbies: ___________________________________________________________________________________________

____________________________________________________________________________________________

Schedule:

1st Block: _____________________________ Time: ________ Teacher: ______________________________

2nd Block: _____________________________ Time: ________ Teacher: ______________________________

3rd Block: _____________________________ Time: ________ Teacher: ______________________________

4th Block: _____________________________ Time: ________ Teacher: ______________________________

Desired Mentee Characteristics: ______________________________________________________________________

_______________________________________________________________________________________________

Other Obligations (employment, family, religious, etc.): ________________________________________________________________________

________________________________________________________________________________________________

To Be Filled Out by SCP

Matched with: _______________________________ Date of Match: __________/___________/________

Match supervisor: ___________________________________________