MENTOR APPLICATION

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Last Name: *

First Name:*

Middle Name:

Gender: *

Male

Female

Phone (xxx-xxx-xxxx):
(Best # to reach you)*

Email:*

Home Address:*

City:*

State:*

Zip:*

I understand that I may gain information about a student that may be considered personal and confidential and should be treated accordingly. I agree that I will not disclose information obtained through my mentor relationship with a student to any third party who is not affiliated with the school. I further understand that any unauthorized disclosure of student information may be a violation of Georgia and Federal law.

Please choose your availability for an interview:

Mon
Tue
Wed
Thu
Fri

Employed: *

Yes

Are you a current GCPS Employee:*

Yes