Full Legal Name Gender Date of birth Ethnicity Mailing Address Address line 1 Address line 2 City State Zip Email Address Preferred Contact Method Home PhoneCell PhoneWork Phone Preferred Phone Number Optional additional phone number Optional additional phone number Employment information - type "N/A" if any of the following are not applicable. Employer Length of employment Job title May we contact you at work? YesNo Education completed High School - Yes or No Other? 2-year degree School 4-year degree in School Advanced degree(s) in School How was the Mentorship Program brought to your attention? What motivated you to apply to the Program? What motivated you to apply to the Program? YesNo What are your hobbies, special skills, or other interests? What do you like to do in your leisure? What other affiliations (e.g., service or volunteer organizations) do you have? What do you hope to gain from the mentoring experience? What do you hope your mentee gains from the mentoring experience? Do you have prior mentor experience? YesNo If yes, please explain: (Program Name & Dates) How many students would you like to mentor? OneTwo Mentors often have a set of experiences to share, please help us achieve the best possible match by specifying if you would like to mentor a student from a specific cultural background (if available)? YesNo If yes, what cultural background? Do you consent to a background check, including fingerprints?? YesNo List three people (non-family members) who can serve as character references for you. Person 1 1.) Name Relationship Length of relationship Mailing address line 1 Mailing address line 2 City State Zip Phone Email Person 2 2.) Name Relationship Length of relationship Mailing address line 1 Mailing address line 2 City State Zip Phone Email Person 3 3.) Name Relationship Length of relationship Mailing address line 1 Mailing address line 2 City State Zip Phone Email I certify that the information I have supplied is correct to the best of my knowledge. I grant permission for you to contact the references provided. I also understand and agree to the duties and requirements described in the Volunteer Duties and Requirements. Electronic Signature Date This form uses Akismet to reduce spam. Learn how your data is processed. Δ
