Person currently submitting/reviewing this form:
Student
Program Administrator/Student Supervisor
Student Name
First Name Last Name
Student ASSIST ID#
Student Email
Current Grade Level
EXAMPLE
THIS EXAMPLE IS NOT TO BE USED TO TURN IN, HARD COPY, TO
SOUTHERN'S PFE OFFICE. USE THE ONLINE FORM. THANK YOU.
-
Grade 9
Grade 10
Grade 11
Grade 12
Number of Semesters Worked in ASSIST (including the current semester)
Academy Name
Academy ASSIST Email
In each of the settings listed below, indicate how many senior mentors you were partnered with:
1 2 3 4 5 6+
Nursing Home
Individual Residence
Assisted Living Facility
Retirement Community
Other
Please answer each of the below questions, indicating either Strongly Agree, Agree, Unsure, Disagree, or
Strongly Agree:
Strongly
Agree
Agree Unsure Disagree Strongly
Disagree
I am aware senior citizens in my community are in need of company.
I know what is expected of me when I am working with my senior mentors.
The online reflection profess is easy to understand.
I typically receive approved or denied feedback within two days of submitting my
reflections.
My senior mentor(s) and I enjoy each other's company.
My senior mentor(s) and I learn from each other.
I am making a positive impact with the senior mentor(s) I am partnered with.
I am meeting a need in the community.
Without this job I would most likely not be able to attend my school or academy.
The mission or purpose of the ASSIST Program makes me feel my job is
important.
EXAMPLE
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Andrews Academy, MI
Atlanta Adventist
Academy, GA
Bass Memorial
Academy, MS
Battle Creek Academy,
MI
Blue Mountain
Academy, PA
Campion Academy, CO
Collegedale Academy,
TN
Columbia Adventist
Academy, WA
Fletcher Academy, NC
Gem State Adventist
Academy, ID
Georgia-Cumberland
Academy, GA
Great Lakes Adventist
Academy, MI
Greater Atlanta
Adventist Academy, GA
Greater Miami
Adventist Academy, FL
Greeneville Academy,
TN
Gurnee Christian
School, IL
Higher Ground Mission
School, NM
Highland Academy, TN
Highland Adventist
School, WV
Highland View
Academy, MD
Hinsdale Adventist
Academy, IL
Indiana Academy, IN
Jefferson Christian
Academy, TX
Madison Academy, TN
Maplewood Academy,
MN
Midland Adventist
Academy, KS
Mile High Academy, CO
Milo Adventist
Academy, WA
Mount Ellis Academy,
MT
Mount Pisgah Academy,
NC
Ozark Adventist
Academy, AR
Pine Forge Academy,
PA
Pine Tree Academy, ME
Portland Adventist
Academy, OR
Puget Sound Adventist
Academy, WA
Richmond Academy, VA
Rio Lindo Adventist
Academy, CA
Riverview Memorial
School, ME
Rogue Valley Adventist
Academy, OR
Savannah Adventist
Christian School, GA
Shenandoah Valley
Academy, VA
Skagit Adventist
Academy, WA
Spring Valley Academy,
OH
Takoma Academy, MD
Upper Columbia
Academy, WA
Vienna Adventist
Academy, VA
Vine Haven Adventist
School, NJ
TEST ACADEMY (do
not choose)
What have you learned from visiting with your senior mentor?
What is one (or more) area in which you could improve on regarding your work in the ASSIST Program?
Do you think you would be interested in a career working in the senior care industry? Examples: Working
as a nurse, activities director, nursing home/assisted living manager, or other job in which seniors live.
Yes
No
Is there anything you would like to say to the people who fund the ASSIST Program?
Do you have any suggestions, experiences, or thoughts you would like to let us know about?
EXAMPLE
Program Administrator Password
Please answer the following questions as truthfully and accurately as possible:
Always Frequently Sometimes Seldom Never N/A
This student shows up for work on time.
This student takes initiative and is engaged with their senior mentor.
This student represents the school well.
This student is committed to interacting and learning from their senior
mentor.
This student demonstrates a genuine care for his/her senior mentor.
This student submits their visitation reflections on-time.
Please include any other feedback or information, including any praises or concerns pertaining to this
student's work in ASSIST:
EXAMPLE
Submit
Please answer the following questions as truthfully and accurately as possible:
Always
Frequently Sometimes Seldom Never
This students is engaged with the senior mentor(s).
This student and his/her senior mentor(s) interact and learn from each other.
This student is aware of the needs of his/her senior mentor(s).
This student is an advocate for his/her senior mentor(s).
This student is respectful and considerate of staff members.
This student engages in one-to-one activities with his/her senior mentor over group
activities.
Would you like to provide any additional comments?
Please answer the following questions as truthfully and accurately as possible:
Always Frequently Sometimes Seldom Never
My student mentee is engaged with me when he/she is visiting.
My students mentee takes initiative.
My student mentee is thougtful and considerate.
Would you say you have developed a personal relationship with your student?
Yes
No
EXAMPLE
What are some of the activities you and your student do together?
What are some things your student does for you?
What do you appreciate most about your student?
Did a representative from the school visit you to explain the expectations of the visit?
Yes
No
Would you like to discuss any areas your student could improve or additional comments?
Do you have another senior mentor's feedback to add?
Yes
No
Please answer the following questions as truthfully and accurately as possible:
AlwaysFrequentlySometimesSeldomNeverMy student mentee is engaged with me when he/she is visiting.My students mentee takes initiative.My student mentee is thougtful and considerate.
Would you say you have developed a personal relationship with your student?
YesNo
What are some of the activities you and your student do together?What are some things your student does for you?What do you appreciate most about your student?Did a representative from the school visit you to explain the expectations of the visit?
YesNo
Would you like to discuss any areas your student could improve or additional comments?Do you have another senior mentor's feedback to add?
YesNo
Please answer the following questions as truthfully and accurately as possible:
AlwaysFrequentlySometimesSeldomNeverMy student mentee is engaged with me when he/she is visiting.My students mentee takes initiative.My student mentee is thougtful and considerate.
Would you say you have developed a personal relationship with your student?
YesNo
What are some of the activities you and your student do together?What are some things your student does for you?What do you appreciate most about your student?Did a representative from the school visit you to explain the expectations of the visit?
YesNo
Would you like to discuss any areas your student could improve or additional comments?
What is the status of this performance review?
Still in Progress
All Sections are Finished
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