Mentor Application

Your Information: * Required fields

Your Name (First Middle Last):*

Your Email:*

Salutation:

Birthdate (mm/dd/yyyy): *

Gender:*

Ethnicity: * Other:

Home Address
Street: *

City: *

State: *

Zip: *

Home Phone (000-000-0000): *

Cell Phone (000-000-0000): *

Marital Status (single, married, divorced): *

Spouse's Name:

Number of Children:

Ages of Children (separate with commas):

Have you lived in the state entered on the line above consecutively for the past 10 years?*

Current Occupation: *

Hours of Employment (9-5, 8-4 etc.):

Best time to contact you? *

May we call you at work? *

Company:

Street Address:

City:

State:

Zip:

Work Phone:

Fax: (000-000-0000):

What other languages do you speak?:

Have you ever been convicted of a crime, or are you currently released on bail, or on your own recognizance for any crime? *

Have you ever been cited for driving under the influence (DUI) in the past ten years? *

Do you object to our checking with appropriate authorities such as the Department of Justice, Federal Bureau of Investigation and the California Department of Motor Vehicles for matters of public record regarding your background and history? *

Who (or what) referred you to this Mentor Project?

Please list the names and complete addresses of one work reference. (References will have known you at least two years and are willing to discuss your character, reputation, and ethics.)

Reference

Name (First Middle Last): *

Salutation:

Street Address:

City:

State:

Zip:

Phone (000-000-0000): *

Email: *

Drivers License and Insurance Information:

State Issuing Driver License: *

Drivers License ID Number: *

Driver License Expiration Date (00/00/0000): *

Auto Insurance Carrier: *

Do you know someone else who might be interested in being a mentor?

Name:

Email:

Phone (000-000-0000):

Anything else you'd like us to know about why you are interested in becoming a mentor?

City of Dreams does not discriminate on the basis of race, creed, educational level, physical disability, age, gender, sexual orientation, or marital status.

The above information is true to the best of my knowledge. I understand that I am not obligated, if called upon, to perform volunteer mentor services herein applied for, and that the agency is not obligated to assign, or actively seek to assign a student to me. I further agree to allow City of Dreams to elicit additional pertinent, personal information as part of the matching process.

In the event that I am chosen to mentor a youth, I agree to the commitment and to participate to the best of my ability. I will honor confidential information regarding my student. I will be free of the influence of alcohol or illegal drugs when with students on or off school grounds. I will inform the Project Coordinator of any changes in my address and/or phone numbers. I will inform the Project Coordinator in advance should I choose to stop volunteering.

Check this box to signify that you accept these terms before submitting this form: