Community Youth Advance · Community Youth Advance Mentor Form

Contact Information

Please choose a Mentoring Program

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Mentoring to Manhood (Community - Prince George's County)

Lily Sisterhood (@Brookland Middle School)

Brookland Boys (@Brookland Middle School)

Prefix

Mr.

Mrs.

Ms.

Dr.

Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Email

Verify Email

Mobile Phone

Date Of Birth (MM/DD/YYYY)

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(mm/dd/yyyy)

How long have you lived at this address?

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Marital Status

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Single

Married

Widowed

Separated

Divorced

Age

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Educational and Professional Background

What is your highest level of education completed?

High-school/GED

Trade/Technical School

Undergraduate/College

Graduate School

Doctorate

Please list your former high school and if applicable your college and graduate alma maters

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Are you from Prince George's County?

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Where are you from or where did your grow up?

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Are you military/former military?

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Yes

No

Job Title

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Organization/Employer

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Job description

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Length of current employment?

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Do you expect any change in your employment status during the next year?

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Yes

No

Can you be contacted at work?

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Criminal History Check

Have you ever been charged with any criminal offense?

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Yes

No

If yes, what were you charged with? *If no, please write N/A Your answer

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Please list three personal or professional references. Name and phone number

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Additional Information

Please briefly state why you want to become a youth mentor. Please indicate any personal qualities and relevant experiences with leading and developing others.

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Please describe your prior experience with being a mentor or volunteering with youth.

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How do you want to volunteer?

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M2M Mentor

M2M Brookland Mentor

Lily Mentor

After School Tutor (Maryland)

After School Tutor (DC)

Other:

Are you willing to commit to at least 5 hours per month for the duration or the school year?

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Are you interested in being matched with a mentee for one on one mentorship

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Do you have any specific preferences in terms of the mentee you would like to mentor?

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How did you learn about our mentor programs?

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Current Mentor or Volunteer

Parent

Newspaper/Ad

Website

Radio

other

Do you have any colleagues who may be interested in becoming a mentor with CYA

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Please list your colleagues name and contact information

Volunteer Agreement

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CERTIFICATION: I hereby certify that the information contained in this application is true, correct and complete. AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the references, employers, and educational institutions listed above, and any and all other individuals and entities contacted by CYAdvance for information about me, to release all information. RELEASE FROM LIABILITY: I release all parties and persons from any and all liability for any damages, which may result from furnishing such information to CYAdvance, as well as from the use or disclosure of such information by CYAdvance or any of its agents, co-workers or representatives. The undersigned acknowledges and agrees to the above-stated information and that:

1) Any misrepresentation, falsification or material omission of information on this application may result in my failure to be accepted as a mentor or a volunteer.

2) That the agency is not obligated to assign or actively seek to assign a mentee.

3) As a part of the agency’s matching process, additional information will be reported from the applicant and a background check will be completed.

4) The applicant agrees to allow CYAdvance to use his/her image for marketing and recruitment purposes.

By digitally selecting "Yes" below, you are acknowledging that all the information provided is accurate. If you have questions about the CYAdvance volunteer intake process, please call our office at 240-770-3870 or e-mail us at mentor@m2minc.org. *

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Yes

No

Signature

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Please enter your first and last name to submit your digital signature.