High School Peer Mentor Application

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2023-2024 School Year the program will take place from 3:15 pm - 4:15 pm due to the change in the school dismissal hours.

First Name *

Last Name *

Mobile Phone *

Date of Birth *

YYYY

Gender (for matching purposes) *

Male

Female

Prefer not to say

Other:

Grade *

Please list all clubs, teams, organizations, or groups which you belong to or competed in school. *

Please list all acts of COMMUNITY SERVICE (volunteer activities) in and outside of school. *

Please list your top 3 hobbies or interests: (ex: Arts/Crafts, Sports, Sing/Music, Board Games) *

Please check all activities you are interested in: *

Biking

Camping

Science

Cooking

Library

Hiking

Yoga

Boating

Music

Sports

Golf

Swimming

Gardening

Parks

Movies

Fishing

Animals/Pets

Painting/Photos

Board Games

Shopping

Required

Please list the top 3 things you would do with your mentee: *

Reference 1 - First and Last Name *

Email Address *

Reference 2- First and Last Name *

Email Address *

I, hereby certify that all the above is correct to the best of my knowledge. As a maturing young adult, I would testify to the previously listed information. I understand that this form is an application and I will be contacted by the Mentoring Program Coordinator of the Club M program. If accepted, I promise to abide by the rules of the program which will be provided at training. (your name typed below signifies your agreement). *

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