Student Application Form
Please fill out the form below. Fields marked with a
red *
are required.
Student id:
First Name:
Last Name:
Race/Culture:
African American
Multi Racial
Russ Old Bel
Russ Otho
Native American
Native Alaskan
Latino/Hispanic
Asian Indian
Latin American
Caucasian
Asian
Other
Street:
Apt:
City:
State:
Zip:
Gender:
Male
Female
School:
Burbank
Cullen
EO Smith
Fleming
Fonville
Hamilton
Hogg
Marshall
McReynolds
P. Henry
Ryan
Grade:
6
7
8
Phone:
Emergency phone:
Please list your interests/hobbies:
What is your favorite thing to do in school?
What is your favorite thing to do outside of school?
Why would you like a Mentor?
What are some of the things you would like a Mentor to help you with?
What kind of person would you like your Mentor to be?
Would you prefer that your Mentor be the same race or culture as you?
Yes
No
Doesn't Matter
Registration date:
Friday, September 10, 2010
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