Student Mentor Application

You will need some additional information to complete this application, including: parent employment information, and siblings’ names and ages.

If you need to, you can save your progress and return to your application.

Student Personal Contact Information

First Name *This question is required.

Middle Name

Preferred Name

Last Name *This question is required.

Street Address *This question is required.

Apt/Suite

City *This question is required.

Zip/Postal Code *This question is required.

Student Email Address *This question is required. This question requires a valid email address.

Parent Email Address *This question is required. This question requires a valid email address.

Student Phone Number *This question is required.

Parent Phone Number *This question is required.

If you said others, what school?

Student ID #

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

How would you describe your gender? *This question is required.

If you said other, please specify.

How would you describe your race/ethnicity? *This question is required.

If you said other, please specify. *This question is required.

If you said other, what is your primary language?

Do you speak any other language(s)? *This question is required.

What other languages do you speak? *This question is required.

American Sign Language
Amharic
Arabic
Chinese

Creole
English
French
Portuguese

Russian
Spanish
Other

If you said other, what language?

Are you a U.S. citizen? *This question is required.

Do you have a FL Prepaid Plan? *This question is required.

Do you receive free or reduced priced lunch? *This question is required.

Is your family income less than $70,000? *This question is required.

Student Mentor Application

Section A