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  3. December
  4. C
  5. Child (Mentee) Application 2014
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Exit Survey
 
 
Hello:

Thank you for your interest in POSI+IVI+Y Mentoring! We are so excited to have you. We are accepting applications on a rolling basis. Also, please note that the program meets on Fridays from 3:30-5:00pm starting in January.

More information will be given via e-mail.

Thank you very much!
 
 
Child's Information
* First/Last Name : 
* Gender : 
Address 1 : 
Address 2 : 
City : 
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Email Address : 
 
 
 
* Age : 
* Grade : 
 
 
 
Date of birth:
 
 
 
Hobbies : 
Talent/Skills : 
Honors and Awards : 
 
 
 
Career Goals : 
Life Goals : 
 
 
 
Tell us a little about yourself!:
   
 
 
 
Who is your role model? : 
How did you hear about POSI+IVI+Y Mentoring? : 
 
 
 
What do you most wish to learn with your mentor?
   
 
 
 
Do you have any special requests for a mentor?
   
 
 
Parent or Guardian Contact Information:
* First/Last Name : 
* Relationship : 
Address 1 : 
Address 2 : 
City : 
State : 
Zip : 
* Phone : 
* Email Address : 
 
www.PositivityMentoring.com | POSI+IVI+Y Mentoring | [email protected]