First Name * MI Last Name * Birth Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 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 * - Select -CaucasianAfrican AmericanHispanicAsianNative AmericanOther Other Ethnicity * Age * - Select -18 - 3031 - 4041 - 5051 - 6061+ Married * - Select -YesNo Children * - Select -YesNo Daughters 0123456789 Ages Sons 0123456789 Ages Education * some schooling, not a high school graduateGEDhigh school graduateVo/Tech certificateassociate's degreebachelor's degreemaster's degreedoctorateother 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 No 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) SportsHandicraftsOutdoor lifeMechanicsScienceLiteraturePop culture (Movies, TV, etc.)CollectingOther Favorite sports * Favorite handicrafts * Other activities * Is there anything else you would like us to know about you?