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MENTORS 4 COLLEGE STUDENT DATA FORM (V.23)
INFORMATION ABOUT STUDENT
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1.
Student FIRST name
(Required.)
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2.
Student LAST name
(Required.)
3.
Who is filling out this form?
Student
Parent, Guardian or Other Person
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4.
Student telephone contact information (Please enter ONLY the student's cell phone number, not a parent cell phone)
(Required.)
Student cell phone number
*
5.
Student email contact information (Please enter ONLY the student's email, not a parent email):
(Required.)
Student PRIMARY email address (DO NOT use your school district email address! Some districts block our emails since we're outside the district.)
Student ALTERNATE email address (if you have more than one)
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6.
What's the best way to get in touch with student?
(Required.)
Call student's home phone
Call student's cell phone
Text to student's cell phone
Email student
Email parents
Call parent's cell phone
Text to parent's cell phone
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7.
What High School does student attend?
(Required.)
Affton High
Bayless High
Clayton High
Fort Zumwalt East
Fort Zumwalt West
Francis Howell High
Francis Howell Central
Francis Howell North
Francis Howell Union
Kirkwood High
Hollywood High
Junipero Serra High
Ladue High
Lindbergh High
McCluer High
McCluer North High
McClure South High & STEAM Academy
Palmdale Academy
Parkway Central
Parkway North
Parkway South
Parkway West
Ritenour High
Riverview Gardens High
Rockwood Lafayette
Rockwood Marquette
Rockwood Summit
St Louis Public Schools
Staples High
Wentzville Holt
Wentzville Liberty
Wentzville North Point
Wentzville Timberland
Other (please specify)
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8.
Year student will graduate High School
(Required.)
2024
2025
2026
2027
2028
2029
2030
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9.
What pronouns does student prefer to use?
(Required.)
they/them/theirs
she/her/hers
he/him/his
zie/hir/hirs
ze/zir/zirs
Other (please specify)
*
10.
Student's nationality/race
(Required.)
White
Black/African American
Latino/Hispanic
Asian
Indian
Other (please specify)
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11.
How did your family first hear about Mentors 4 College?
(Required.)
One of my siblings was in the Mentors 4 College program
Counselor/Teacher at school
Student friend
Parent Friend
I'm an Aim High student or graduate
EST in California (Educating Students Together)
Twitter
Instagram
Facebook page
Mentors 4 College web site
Mentors 4 College lecture or webinar
Other (please specify)
12.
If student has a sibling who was mentored through the Mentors 4 College program, please tell us this sibling's name
*
13.
What zip code does student live in?
(Required.)
*
14.
Does student have access to the internet, plus a tablet, laptop or desktop computer outside of school hours, during evenings and weekends (access can be at home, at a library, at a neighbor's or relative's, at a coffee shop, etc)?
(Required.)
Yes, student has internet access AND a tablet, laptop or desktop computer outside of school hours
No, student ONLY has access to a smartphone outside of school hours
No, student has no internet access outside of school hours
14%
