Project GRAD Houston

Mentor Application Form

Please fill out the form below. Fields marked with a red * are required.

TX Drivers Liscense :
First Name:
Last Name:
Race/Culture:
Street:
Apt:
City:
State:
Zip:
Gender:	Male Female
Day Phone:
Evening Phone:
Emergency Phone:
Occupation:
Interests/Hobbies:
Days and Times most available to meet:

Have you ever participated in a program like this before?
	Yes No
If "YES" please describe the program:

What do you believe are some of your strengths that you can bring to this program? (For example, having previous mentor-type experience, being good at a particular school subject, being bilingual, having ability to relate with kids, etc.):

Describe the age and type of student you would like to mentor:

Though Mentors may eventually provide all the following to their students, which role would you be most interested in?
	Tutor Special Friend Role Model Career Coach
Describe other roles you would be interested in:

Registration date:	Wednesday, December 31, 1969