Become a Mentor Form

First Name *

Middle Initial *

Last Name *

Gender *

Male

Female

Date of Birth *

Ethnicity

Mailing Address *

City *

State *

Zip *

E-mail *

Preferred Contact Number *

Home Phone	Cell Phone
Work Phone

Home Phone

Cell Phone

Work Phone

Employer

Length of Employment

Job Title

May we contact you at work?

Yes

No

High School

Other

2-year degree in

School

4-year degree in

School

Advanced degree(s) in

School

How was the Program brought to your attention?

What motivated you to apply to the Program?

Will you be able to meet with a student at least once a month during the school year?

Yes

No

What are your hobbies, special skills, or other interests?

What do you like to do in your leisure?

What other affiliations 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?

Yes

No

Please explain

How many students would you like to mentor?

1

2

Mentors often have a particular 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)?

Yes

No

what cultural background?

Is there a particular student you would like to mentor?

Yes

No

List three people (non family members) who can serve as character references for you.

Name

Relationship

For how many years?

Mailing Address

City

State

Zip

Name

Relationship

For how many years?

Mailing Address

City

State

Zip

Name

Relationship

For how many years?

Mailing Address

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.

Signature *

Date *