GEM MENTOR APPLICATION FORM

This form is for high schooler interested in being paired with a Big Sib or mentor who is an upperclassman or in college.
Student's First Name*
Student's Last Name*
Student's Email*
example@example.com
Student's Phone Number*
Please enter a valid phone number.
Age*
Numbers Only
Grade*
Name of School*
Have you ever had a mentor or a BigSib before?*

YesNo
Was it beneficial?*

YesNo
What do you like to do in your free time?*
What is the last movie you saw?*
What is the last book you read?*
Where do you see yourself 10 years from now?*
Is there anything you are struggling with? Is there a subject in school that is extra difficult for you? Is there something in your personal life?*
What is a personal accomplishment that you are proud of?*
Parent's Contact Information
Mother Full Name*

First NameLast Name
Mother Email*
example@example.com
Mother Phone Number*
Please enter a valid phone number.
Father Full Name*

First NameLast Name
Father Email*
example@example.com
Email Phone Number*
Please enter a valid phone number.
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Select all that applies to you*

Parent of ElementaryParent of Middle SchoolParent of High SchoolParent of a College Student
How did you hear about GEM?*

FacebookInstagramWhatsappEmailTextFriendNewsletterRepresentative calledReceived postcardOther
Informed Consent and Liability
Relation to the attendee*
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Parent's Contact Information