Site Based Programs - Mentee Nomination Form CHILD INFORMATIONFull Name of Child* First Last Other name or chosen name of Child (Optional) Preferred Pronouns (Optional) School* Grade* Date of Birth* MM slash DD slash YYYY Full Name of Teacher* Teacher Email* Enter Email Confirm Email GETTING TO KNOW THE MENTEEThis information will help us to get to know the student and assist us to find a mentor who is a good fit.Why would this student benefit from having a mentor?*Does the student want a mentor?*How would you characterize the student's behaviour/personality?*Please list any emotional or behavioural difficulties this student is experiencing.*Is there anything you would like us to be aware of that would assist us in finding the right mentor for the student?*Has the student had any involvement with other professionals?* Yes No If yes, please provide more infomation about other professionals.*Does the student have a behaviour designation?* Yes No If yes, please provide the designations(s).*Please check any of the following characteristics that describe the child:* Active Friendly Helpful Outgoing Shy Withdrawn Other: Please specify below Other characteristic(s):* Please check any of the following that describes the child’s interests:* Animals Arts and Crafts Board/Card Games Building (Lego/Wood) Computer/Video Games Cooking Music Movies/TV Playground/Outside Reading Sports Other: Please specify below Other interest(s):* The following information is collected for matching and statistical purposes only and does not indicate participation requirements.Is this student new to Canada? Yes No How long has the child lived in Canada? Ethnicity Additional Languages Spoken NOMINATOR INFORMATIONFull Name* Position* Email* Enter Email Confirm Email Date of Submission* MM slash DD slash YYYY
