Mentor Questionnaire

Full Name

Business Name

Business Address

City

Zip Code

Job Title

Description of Duties

Work Phone

Cell or Home Phone Number

E-mail

Highest Level of Degree

Bachelor's Degree
Master's Degree
Doctorate
Other:

To assist us in the student-to-mentor matching process, please check each of the following that best describes you:

Strongest subjects when you were in school

Type of Music You Like to Listen to or Artist

Please rank your interest in: field trips

	1	2	3
Interested				Not Interested

Please rank your interest in: improving study habits

	1	2	3
Interested				Not Interested

Please rank your interest in: holiday events

	1	2	3
Interested				Not Interested

Please rank your interest in: reading

	1	2	3
Interested				Not Interested

Please rank your interest in: school projects

	1	2	3
Interested				Not Interested

Please rank your interest in: art projects

	1	2	3
Interested				Not Interested

Please rank your interest in: help with homework

	1	2	3
Interested				Not Interested

Please rank your interest in: movies

	1	2	3
Interested				Not Interested

Please rank your interest in: finding out about careers

	1	2	3
Interested				Not Interested

Please rank your interest in: museums

	1	2	3
Interested				Not Interested

Please rank your interest in: computer projects

	1	2	3
Interested				Not Interested

Please rank your interest in: science projects

	1	2	3
Interested				Not Interested

Please rank your interest in: music programs

	1	2	3
Interested				Not Interested

Please rank your interest in: collecting (coins, rocks, etc.)

	1	2	3
Interested				Not Interested

Please rank your interest in: animals (zoos, farms, pets)

	1	2	3
Interested				Not Interested

Please rank your interest in: indoor activities

	1	2	3
Interested				Not Interested

Please rank your interest in: outdoor activities

	1	2	3
Interested				Not Interested

Please rank your interest in: outdoor activities

	1	2	3
Interested				Not Interested

Briefly list current and past work experience:

List any other interests or hobbies:

Anything else you would like to share, add, or alert the Puente Project of?