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* 1. School name

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* 2. Date

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* 3. Your name

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* 4. Student Name

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* 5. Grade level

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* 6. I was asked to nominate students this year to be enrolled in the mentoring program:

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* 7. I was asked for a convenient time for the child/ren to be taken out of the classroom so the student is not missing academic time:

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* 8. Please indicate the level of contact you have had with mentors who worked with your students: (check all that apply)

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* 9. Overall, mentoring has helped my student(s):

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* 10. What do you think might improve the mentoring program at your school or site?

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* 11. Please rate the changes in your student over this past year based on the effects on the mentoring relationship. If more than one student from your class was mentored, please complete the chart on the experience you feel most beneficial for us to know or compete a survey for each student individually.

  Much better Better No change Worse Much worse Don't know
Shows respect for adults
Relationship with peers
Self confidence
Self control
Cooperation
Responsibility
Decision making skills
Attendance
Initiative
Works well with others
Academic performance
Completes homework
Pays attention
Follows directions
Attitude towards learning
Participates in class

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* 12. Additional Comments:

Thank you for completing our survey!

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