I CARE Mentoring foundation


IC.A.R.E. Mentoring Intake Referral Form



Please complete as much information as possible when making this referral. Please talk with the student about the I C.A.R.E. Mentoring program and why you think the student might like to have a mentor. It is important to verify that the student wants a mentor before making the referral.

Only students who were absent 13 days or less and or have more than 3 behavioral referrals in the previous school year are eligible for I C.A.R.E. The program considers a student as absent if they miss more than half their periods per day.

* indicates a required field.

Student's School information

County*
District*
School*

Student information

First name*
Last name*
Grade*
Sex*
Ethnicity*
Date Of Birth MM/DD/YYYY*
Age*
Student School District ID Number*

Your Information

Your First and last Name*
Your Phone Number*
Your Email Address*
Your Relationship To Student*
Check this box if you work with this student in an after-school program.

Guardian Information

Parent/Guardian Name (First and last)*
Parent/Guardian Phone Number*
Alternative Or Work Phone Number*
 
Parent/Guardian Email Address*
Home Street Address*
Appartment Number*
City*
Zip code*

Student Interests (check all that apply)

Theater
Music
Outdoor Activities
Sports And Fitness
Blog
Fashion
Arts And Crafts
Culinary
Board Games
Video Games
Anime, Cartoons and/or Comics
Reading
Other special interests or details a mentor would want to know.

Areas of Concern (check all that apply)

Academics
Family_Support
Attendance
Adult Relationships
Social Skills
Self-Esteem
Other

When is the student available for mentoring?

Breakfast
Lunch
Specials
Other

Additional Information

Special Services/Disability

Check here if the student receives special services due to a disability.
Please Explain
Check this box if English is this student's second language.

GOALS, CHALLENGES, AND OPPORTUNITIES

Please discuss goals, challenges and promising opportunities that could be addressed through mentoring.

From your interaction with this student, what would be a good goal for the mentor and the student to work on?
What challenges does this student face that they would need extra help and support to overcome?  Academically and holistically?
What promising characteristics does this student demonstrate that would cause you to believe they would want to be mentored?
Check here to verify that you have talked with the student's guardian about I C.A.R.E. Mentoring.
Check here to verify that you have talked to this student about I C.A.R.E. Mentoring.