First Name * MI Last Name * Birth Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 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?