Perry Mentorship Program

Perry High School

3737 13th Street S.W.

Massillon, OH  44646

 

MENTORSHIP EMERGENCY INFORMATION

*  Specific medical/emergency release information is filed in the high school office.

STUDENT’S NAME  ___________________________________________________________

PARENT/GUARDIAN  _________________________________________________________

ADDRESS  __________________________________________________________________

HOME TELEPHONE  ______________  BUSINESS  ___________________________________

MENTOR’S NAME  ___________________________________________________________

JOB SITE LOCATION  _________________________________________________________

ADDRESS  __________________________________________________________________

BUSINESS TELEPHONE  ________________________            HOME  ____________________

SCHOOL COUNSELOR  ________________________________________________________

SCHOOL TELEPHONE  ________________________________________________________

 

COPIES:

            Student

            Office

            Mentor