For Women - Be a Mentor

Please complete the following form in order to ensure that Big Brother Big Sisters identifies this inquiry as a Girls Rise Up match. By completing the below, you are authorizing Girls Rise Up to share the following information with Big Brothers Big Sisters: contact information (email, phone number, address), basic demographic information including date of birth, and match information. After you submit this form, you will be contacted by a Big Brothers Big Sisters Twin Cities representative regarding next steps. We thank you for your interest in becoming a mentor!

Name:

First Name

Last Name

Email:

Phone:

(###)

###

####

City of residence:

I am willing to travel farther than the standard 15-20 miles to be matched with a girl.

Yes

No

I have experienced the loss of my mother through death.

Yes

No

The loss of my mother occurred over 1 year ago.

Yes

No

I would like to mentor a specific girl.

Yes

No

The girl's name is: (optional)

First Name

Last Name

Please include any additional information you feel is important below:

Electronic Signature:

First Name

Last Name

For Women - Be a Mentor

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