Mentee Application


This application is for students at BURTON ELEMENTARY. 

If the person completing this form is someone other than the student's parent/guardian, a Student Information Release Form must be completed by the parent/guardian prior to referring the student. [These forms are available in the Mentor Center or by e-mailing]

Please click "submit" when complete. Thank you!

* Required field
Basic Information
* First Name
Middle Name
* Last Name
Date of Birth
Contact Information
Demographic Information
* Gender
Primary Religion
* Other Ethnicity
Primary Language
Other Primary Language
Secondary Language
Other Secondary Language
Medical Information
Medical Conditions
Medical Conditions Allergies
Additional Information
Types of Challenges
Challenges Other
Description of Challenge
Mentee From Home With a History of
Address Information
Address 1
Address 2
Zip Code
Other Information
Family Structure
* Other Family Structure
Career Focused Interests
Interests Other
Referral Information
Referral Source
* Other Referral Source
Referral Comments
Referral Date
Emergency Contact Information
Primary Emergency Contact
PEC Name
PEC Relationship
PEC Home Phone
PEC Mobile Phone
PEC Work Phone
Primary Emergency Contact Email
Program Questions
T-Shirt Size
Has a Student Information Release Form been signed by a parent/guardian? [Green Form]
* On a scale of 1-4, how high of a priority is this referral? [1 is high, 4 is low]
* Strengths
* Personality type/traits [i.e., reserved, talkative, passive, careful, orderly, spontaneous, impulsive, strong-willed, etc]
* How could a mentor help address these academic, emotional and/or social challenges?
* What other support services are being provided to this student?
* Referred by [name]