In School Mentoring Program Student Referral Form Big Brothers Big Sisters of Miramichi In School Mentoring Program Student Referral Form Referral For* (Student's name)Grade* School* Date of Birth* MM slash DD slash YYYY Age* Gender* M F Parent/Guardian* Phone Number (Parent/Guardian)*Mailing Address (Parent/Guardian)* Street Address Address Line 2 City Postal Code Child needs help with (Please check all that apply)* Self confidence Self control Cooperation Responsibility Listening attentively Following directions Completing tasks Attendance Reading Writing Spelling Mathematics Describe child's family* Only child Two parent family One parent family Lives with grandparents Foster parents Other If other, explain* Please check any of the following which relates to this student* gets along well with peers is a leader relates well to teachers turns in assignments promptly works to full potential in class fights on school grounds never needs detention attends class regularly is cooperative with others teacher's aide is a loner is active in extracurricular activities participates in class is confident has detention regularly defiant with authority seeks attention through negative behavior lacks motivation receives tutor or resource help Medical conditions* Epilepsy ADHD/ADD Asthma Allergies Medications Other Other medical conditions* If student has allergies, what are they?*Medications?*Please suggest the best day and time for the volunteer to meet with the student? Please enter two options.Day/Time - Option 1* Day/Time - Option 2* Your Name* Your Email* Today's Date MM slash DD slash YYYY Δ
