Peer Mentoring Application Form

ADA MERRITT K-8 CENTER

Peer Mentoring Application Form

Selected middle school students will have the opportunity to serve as peer mentors and provide assistance to students in the lower grades during the after school program from 3:00 p.m. to 4:00 p.m.

To be eligible students need to:

o  Complete this application and submit it to Ms. Hesami.

o  Maintain a minimum 3.0 grade point average in all subject areas.

o  Have excellent conduct and effort grades.

o  Be consistently punctual and in attendance.

o  Have their parents’ signed permission to participate.

o  Be recommended by three teachers.

o  Follow school rules.

o  Adhere to all Code of Student Conduct

In order to receive Community and Service credit for these activities at the end of the year, students will need to turn in their participation log along with a Community and Service Reflection Form to Ms. Hesami.

Personal Information

Print Student’s Name: ______Grade: ______

Areas of interest:
Mentoring

Day(s) when you will be able to participate in this program from 3:00 p.m. to 4:00 p.m.:
Monday Tuesday Thursday Friday
Parent Permission
Yes, I give my child permission to become a Mentor at Ada Merritt K-8 Center during the days and hours specified above.

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Print Parent’s Name Parent’s Signature Date

References:

Yes, I recommend the above named student for Ada Merritt K-8 Center’s Peer Mentoring Program.

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Print Teacher’s Name Teacher’s Signature Date

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Print Teacher’s Name Teacher’s Signature Date

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Print Teacher’s Name Teacher’s Signature Date