Mentoring Matters Registry

Address

E-mail
Phone Number

- Area Code Phone Number
Mentoring Program-Primary Contact

First Name Last Name
Title/Position
E-mail
Phone Number

- Area Code Phone Number
Program Description
Please describe the target population of youth served
i.e. age, ethnicity, gender, school attendance, foster care youth, youth from a particular religious group, pregnant or parenting youth, etc.

Program Outcomes
1. Does your program have specific or required outcomes?
If yes, check all that apply below
Mentoring Program Outcomes (check top 2 only)

Decrease in disruptive behavior (i.e., reduced detentions, suspensions, behavioral interventions or involvement in the juvenile justice system) Reduced absenteeism and truancy Improvement in character, life skills, social development, pro-social behavior Academic outcomes ( improved GPA, Passage of EOC/EOG, on-time grade promotion/transition to middle or high school On time high school graduation
Describe how you measure outcomes achieved
Evidence-based Survey; Program Developed Pre/Post Survey; Self-report; External Evaluation; etc.
Mentoring Matters Registry

Thank you for completing this survey. The information you have provided will help us to have a fuller picture of mentoring in our community and include your program on the full registry listing.
Registry Application completed by:

First Name Last Name
Date

- Month - Day Year
Date
E-mail
Enter the message as it's shown *
Should be Empty:

	African American	Asian	Bi-Racial/Multi-Racial	Latino/Hispanic	Native Hawaiian/Pacific Islander	White, not Hispanic	Other
Males 6-10
Males 11-14
Males 15-19
Males 20-24
Females 6-10
Females 11-14
Females 15-19
Females 20-24

	Males 14-18	Males 19-59	Males 60+	Females 14-18	Females 19-59	Females 60+
African American
Asian
Bi-Racial/Multi-Racial
Latino(a)/Hispanic
Native Hawaiian/Pacific Islander
White, not Hispanic
Other