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Matching Form

Name *

First

Last

I think I would be satisfied and best suited to work with a child with a physical problem or disability *

I think I would be satisfied and best suited to work with a child who may have an emotional disability *

I think I would be satisfied and best suited to work with a child who may have a learning disability *

I think I would be satisfied and best suited to work with someone who is doing reasonably well in school *

I think I would be satisfied and best suited to work with someone who is an introvert *

I think I would be satisfied and best suited to work with someone who is an extrovert *

I think I would be satisfied and best suited to work with someone who has an interest in one of the following *

Math English History Reading Computers Music

Choose any that apply

I think I would be satisfied and best suited to work with someone who is at the *

Elementary School Level Middle School Level High School Level

Choose any that apply

Do you have children currently attending Guilford Public Schools? *

Yes No

If you answered yes to the above, please indicate name of school(s) and grade(s *

Please indicate by checking below if you have difficulties with a child who might be or has been: *

A drug user/alcoholic A child who has been sexually molested A child involved with the criminal justice system A child who has been physically abused

We would like to avoid matching you with a student/mentee who you might have a strong objection to working with. It is OK for you to have such objections and your choice does not affect your standing in the program.

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Guilford Youth Mentoring 605 New England Rd Guilford, CT (203)453-2741 Ext. 269