* 1. Name

* 2. Address

* 3. Phone number

* 4. Email Address

* 5. When would you be available to meet with a mentor group? (please check all that apply)

* 6. No childcare is being offered during the mentor groups but some groups will welcome children. Would you be open to a group that welcomes children to be present?

* 7. If yes, what are the ages of the children you would need to bring?

* 8. Any additional comments you'd like for us to know?