Choices4Teens
Mentoring Group

Mentor Application

Make a Difference

In accordance with Chapter 77 of the Acts of 2013, “An Act Relative to Background Checks”, a fingerprint –based state and national criminal record check shall be required for school employees and volunteers.

 

Please complete the form below

Name *
Name
Phone *
Phone
Work
Phone
Phone
Home
Address *
Address
Organizational Affiliations
Note any positions held or honors received (Business, Professional, Civic, Educational and/or Social.
Interested areas of involvement:
Mentoring Bio
How much time would you be able to offer on a weekly basis? *
What is the best day and time for you to meet with your mentee?
I would describe myself as:
What do you like to do most in your free time?
Please indicate any preferences which you have concerning your mentee:
The word "same" refers to yourself – check all that apply
References
Please list the names and addresses of three non-family references
Reference 1
Reference 1
Phone
Phone
Reference 2
Reference 2
Phone
Phone
Reference 3
Reference 3
Phone
Phone
Emergency Contact
Name *
Name
Phone *
Phone