2010-2011 Fountain Hills Mentor Program

Name: ________________________________________________________________________________

Arizona Phone Number: _________________________Out-of-State Phone Number____________________________

Email Address: ___________________________________________________________________________________

____ Yes, I would like to receive mentoring info by email. _____ No, I would like NOT to receive mentoring info by email.

Arizona Address: __________________________________________________________________________________

________________________________________________________________________________________________

Out-of-State Address: ______________________________________________________________________________

________________________________________________________________________________________________

1. Mentored last year at: McDowell Mountain ______ Four Peaks ______ Middle School ______ New Mentor _______

2. Prefer to Mentor in K 1st 2nd 3rd 4th 5th 6th 7th 8th Any Grade

3. I would be willing to mentor a second student either before or after the student I am assigned. ____yes ____no

4. I would like to Mentor with the same teacher I had this year. ________ Yes ________No ________ No Preference

Teacher’s name if yes _______________________________________________________________________

5. I would like to mentor with the same student I had this year. ________________ Yes ________________ No

Student’s name if yes _______________________________________________________________________

6. Date you are available to start Mentoring (ex. after Sept. 1)_____________________________________________

7. Day(s) of week and time(s) you are available to Mentor________________________________________________

___________________________________________________________________________________________

8. Besides English, list other languages spoken_______________________________________________________

9. Work experience and number of years in occupation ________________________________________________

__________________________________________________________________________________________

10. Hobbies, family background, academic strengths, special talents or experiences that you would like to share with a

student _____________________________________________________________________________________

___________________________________________________________________________________________

11. Additional Comments and Requests (Use the back of this form for additional comments & 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,

Please print and mail your completed form to:

The Fountain Hills Mentor Program
c/o McDowell Mt. Elementary School
14825 E. Fayette Drive
Fountain Hills, AZ  85268

This form is also available for printing in .pdf format

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