Mentor Application

First Name *

Last Name *

Birth Date *

Month

Day

Year

Gender *

Female

Male

Street Address *

Street Address Line 2

City *

Zip *

State *

Email *

Mobile Phone *

Job Title *

If not working, describe your situation (e.g. Retired, Seeking work, etc.)

Employer

Work Phone

Ethnicity *

Other Ethnicity *

Age *

Married *

Children *

Daughters

Ages

Sons

Ages

Education *

Select all that apply (Ctrl+click). Details may be requested below.

Vo/Tech cert. in *

from *

associate's in *

from *

bachelor's in *

from *

master's in *

from *

doctorate in *

from *

other degree & field of study *

from *

Are you currently enrolled in any education or training program? *

Yes

Describe the program *

Languages spoken (other than English)

If you have a resume, please upload it

Files must be less than 2 MB.
Allowed file types: txt rtf pdf doc docx odt.

How would you describe your communication style? *

friendly and outgoing

usually wait to be approached by someone new

reserved until I get to know someone

I am interested in becoming a mentor because *

Check all that apply

I think I'd be a positive role model

I like working with youth

I have the time to give

I overcame difficulties growing up and would like to help someone else

I think I have the personality and abilities to be a good mentor

I am interested in making a difference in the life of a young person

I believe in the value of mentoring

I wish I had had a mentor when I was a teenager

I would prefer to mentor *

a female student

a male student

no preference

Are there any particular problems you would prefer not to handle as a mentor?

List any clubs or organizations of which you're currently a member

What activities do you enjoy participating in or watching?

Select all that apply (Ctrl+click)

Favorite sports *

Favorite handicrafts *

Other activities *

Is there anything else you would like us to know about you?

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Mentor Application