Form

First name*

Last name*

Date of birth*

Gender Identity

Pronouns

Not sure what this means? See this pronoun guide from GLSEN.

Email*

Phone number*

Best way to reach you*

School*

Grade/Year in School*

Who lives in your household with you?

Parent/Guardian Name*

Parent/Guardian Phone Number*

Parent/Guardian Email*

How did you hear about UpStreet's Peer Mentoring program?

Why are you interested in particaping in UpStreet's Peer Mentoring program? *

What do you hope to gain from having a peer mentor? *

Do you have any specific concerns or challenges that you hope a peer mentor can help you with? *

What are your favorite parts of school?*

Core subjects, elective classes, social life, athletics, arts, extracurricular activities, etc.

What are your least favorite parts of school? *

How do you like to spend your free time? *

Do you participate in any clubs, teams, sports, or other extracurricular activities? *

Would you prefer a mentor of a particular gender? If so, which?

Is there anything else you would like your peer mentor to know about you prior to being matched with them?