Mentor-Wise

Higher Ground Academy

Mentoring program for students grades 9-12

(Please print)

Your Name: __________________________________________________________________

Mailing Address: ______________________________________________________________

Day Phone: ___________________________ Evening Phone: _________________________

Email Address: _______________________________________________________________

Nationality: _____________________________

Please check the highest level of education completed

—    Some college
—    College graduate
—    Masters degree
—    Doctoral degree (PhD)
—    Post-doctoral work
—    Other____________________________
Community Involvement

1.____________________________________________________________________________________

2.____________________________________________________________________________________

Have your ever been mentored in a formal mentoring program? (e.g. Boys and Girls Club mentoring program, through a school, etc)

Yes      No          If yes, what skills did you learn from your mentor?

If you choose to become a mentor, please indicate your availability:

—    Once a week ,              am  /pm
—    Twice a week,              am/pm
—    Three times a week,    am/ pm
—    Once every two weeks,  am/pm
—    Once a month
—    Saturdays  only,            am/pm
—    Other____________________

If you choose to become a mentor, will you be willing to complete a free mentor training program offered by Higher Ground Academy?
Yes____          No____

Please describe your skill sets/Strengths.
_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

________________________________________________________________________________________

Thank  you for  completing this questioner and for considering to be a part of  our mentoring program.

Please return your completed form to:
Bill Wilson
Executive Director
Higher Ground Academy
1381 Marshall Avenue
Saint Paul MN 55104

On the outside of the envelope, please write: personal and confidential.