G-CODE Mentor Matching Form

Name

DOB

Ethnicity

Address

Occupation

Do you speak any languages other than English

Please List Any Hobbies Or Interests.

Please Select All Words That Describe Your Personality:

Please describe any special talents or experiences you may have had that will help in matching you with a student. (ie: Have you lived in a foreign country, do you know sign language, do you have a particular hobby or interest, etc.)

Please list anything else you would like us to know to help in the matching process. (disabilities, physical restrictions, family status, religion etc ..)

Do you give consent to the use of any photographs of yourself for promotional purposes? Please write your initials next to your answer.

YesNo

Please Initial & Date To Consent To The Terms Above:

MENTOR AGREEMENT:

»Be on time for all scheduled meetings/activities with my mentee.

»Notify G-CODE staff and parent/guardian in advance if I am unable to make any schedule meeting.

»Accept assistance from G-CODE staff and follow all G-CODE rules and procedures.

»Contact G-CODE staff with any questions or concerns.

»Keep discussions with my mentee confidential except in cases of suspected child abuse or neglect as covered in mentor training.

»Notify the G-CODE Director of any changes in employment, address, email, or phone number.

»Check my email regularly for updates and important information.

»Keep a record or log of all meetings/ sessions with mentee for data purposes.

Signature

G-CODE MENTOR MATCHING FORM

As a Volunteer Mentor in The Norwalk Mentor Program, I Agree To The Mentor Agreement Above.