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* 1. Name

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* 2. Gender

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* 3. Grade

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* 4. School Name

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* 5. Teacher's Name or Home Room Teacher

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* 6. Mentor's Name

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* 7. Mentor's Gender

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* 8. Is your mentor a high school student?

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* 9. If yes, from what high school?

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* 10. How many years have you been mentored?

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* 11. If more than one, have you had the same mentor?

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