2022-2023 Mentee Profile Form

I am interested in having a 1-to-1 mentor: *

Yes No
I am committed to communicating with my mentor virtually or face to face. *

Yes No
Student's name * *

First Name Last Name
Student's gender *

Male Female Other
Student's birthday * *

Month Day Year
Student's cell phone number * *

Area Code Phone Number
Student's email * *
Student's home address * *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Student ID number * *
School *

Sequoyah Middle School Lilburn Middle School Cross Keys High School Meadowcreek High School Chamblee Charter High School Dalton Academy McClure High School Lakeside HS Other
Grade *
Parent/Guardian's name * *

First Name Last Name
Parent/Guardian's cell phone number * *

Area Code Phone Number
Parent/Guardian's email * *
Is this your first time having a mentor with the LYLA Program? *

Yes No
Ideal Job/Career
Ideal College/University
What are your favorite subjects in school? Choose all that apply:

Language Arts Social Studies Math Science Foreign Language Fine Arts Music Athletics
How would you describe your personality/interests? Choose all that apply:

Outgoing or Sociable Sports Fan Introverted or Reserved Lover of learning new things Thrill Seeker Health-Conscious Foodie/Home Chef Athletic Nature Enthusiast Pet Person Artistic/Maker
Please tell us about your hobbies and other interests. How do you like to spend your free time?
What are you most passionate about/ what is something that is really important to you? (This could include personal values, community issues, etc.)

Support

	High	Medium	Low
Support
Structure
Information
Involved/present in my life
Verbal communication

What else do you look for in a mentor? Or what do you need/want the most help with? (Characteristics, personality, common interests/hobbies, etc.)
***Other*** Please specify anything else you would like us to consider when matching you with a mentor. (For example: DACA or Undocumented, LGBTQIA+, etc.)
Should be Empty: