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Mentor
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Identifying Information
Name (First Middle Last):
Gender: Male Female
Date of Birth: Social Security Number:
Employer:
Title:
Employment Start Date:
Are you a Take Stock in Children graduate? Yes No
Background Information
Ethnic Group: (check one)
Caucasian African American Hispanic Asian American Indian
Other (please specify)
Age Category: (check one) 18-30 31-40 41-50
51-60
61+
Are you married? Yes No Do you have children? Yes No
# sons
age(s)
# daughters
age(s)
Second Language(s) spoken:
When
you were a teenager, to what income group did your family belong?
low income middle income high income
Contact Information
Home
Addr
ess:
City,
State,
Zip:
Home Phone: Work: Cell:
E-mail
addr
ess