Mentor Request Survey

Request a Mentor/Tutor/Friend

Please fill out this form to request a mentor/tutor/friend for a family. Someone will be in contact with you within the next couple of days to follow up. Please give us as much information as you have available.

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* 1. What is the name of the person submitting this referral and your phone number?

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* 2. Please give us the following information on family members.

Name

Date of Birth/estimated Age

Relationship(mother, son, etc.)

Gender

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* 3. Family Member 2

Name

Date of Birth/Estimated Age

Relationship(mother, son, etc.)

Gender

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* 4. Family Member 3

Name

Date of Birth/Estimated Age

Relationship(mother, son, etc.)

Gender

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* 5. Family Member 4

Name

Date of Birth/Estimated Age

Relationship(mother, son, etc.)

Gender

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* 6. Brief history of family. (Include information on previous career, health concerns, education, journey to the U.S., job in the U.S., schools children attend, and other family in Grand Forks or the surrounding areas)

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* 7. Please give us some more information about the family.

Family's Address

Family's Home Telephone Number

Country of Origin

Native Language

Date of arrival in the U.S.

How good is their English?(Not at all, with key words, some, fairly well, fluently)

Is Grand Forks the first city in the U.S. they have lived?

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* 8. Have you informed the family/individual that you are referring?

Yes

Mentor Request Survey

Request a Mentor/Tutor/Friend

Question Title

* 1. What is the name of the person submitting this referral and your phone number?

Question Title

* 2. Please give us the following information on family members.

Question Title

* 3. Family Member 2

Question Title

* 4. Family Member 3

Question Title

* 5. Family Member 4

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* 6. Brief history of family. (Include information on previous career, health concerns, education, journey to the U.S., job in the U.S., schools children attend, and other family in Grand Forks or the surrounding areas)

Question Title

* 7. Please give us some more information about the family.

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* 8. Have you informed the family/individual that you are referring?

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* 9. Reason for requesting a mentor:

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* 10. Name of LLS New Americans Refugee Resettlement Casework(if known)