Mentee Nomination Form Thank you for nominating a student to our In-School Mentoring Program! This form must be completed in order for the student to participate. Young Person InformationName of School(Required)Full Name of Child(Required)Gender Identity(Required)Date of Birth(Required) MM slash DD slash YYYY Grade(Required)Full Name of Teacher(Required)Teacher Email(Required) * Teacher’s info is to be shared with the Mentoring Coordinator or volunteer for correspondence regarding absenteeism Why would this student benefit from having a mentor?(Required)Does the student want a mentor?(Required) Yes No Unsure but open to learning more How would you characterize the student's behaviour/personality?(Required)Does the student prefer physical activities (i.e. sports, tag, skipping) or non-physical activities (i.e. reading, board games, crafts)? List at least 4 of the student's interests and favourite activities. If uncertain, please ask the student.(Required)Please list any medical issues or concerns this student has. (Allergies, asthma, etc.)(Required)Please list any emotional or behavioural difficulties this student is experiencing.(Required)Has the student's family dealt with professionals/MCFD about any issues?(Required) Yes No Please provide the names of the professionals:(Required)Does the student have a designation?(Required) Yes No Please provide the designation(s):(Required) The following information is collected for matching and statistical purposesIs this student new to Canada? Yes No How long has the child lived in Canada?EthnicityAdditional Language(s) SpokenDoes this student come from a single parent home? Yes No Unknown Nominator InformationFull Name(Required)Position(Required)Email(Required) Please provide any other comments that you would like us to knowPhoneThis field is for validation purposes and should be left unchanged. Share: Facebook Twitter
