Inspired to Learn Online Mentoring or Tutoring Registration Form
Self Advocate Details:
Full Name
*
First Name
Last Name
Age
*
Grade in School (NA if not in school)
*
Services interested in (can select more than one)
*
Peer mentoring/friendship
Academic tutoring
Conversation skills/social skills practice
Other (please specify under hobbies/other comments below)
If Interested in academic tutoring, please indicate subject area(s)
*
Math
Reading/writing
Science
Social Studies
NA; not interested in academic tutoring
Ideal pairing will be with a:
*
Male
Female
Either is great
Availability (days of week/hours free; include weekends if it's an option)
*
Hobbies/Interests or anything else that will help us with the pairing):
*
Parent/Guardian Details:
Full Name
*
First Name
Last Name
Email
*
example@example.com
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Zip code
*
Submit
Should be Empty: