Community Youth Advance Mentor Form

Thank you for your interest in becoming a mentor for our mentoring program!

This form should be completed by an adult 18 or older seeking to become a volunteer mentor for CYA. If you have questions concerning CYA's Mentorship program offerings, please get in touch with us please contact us at info@cyadvance.org and we will be happy to assist. We look forward to working with you!

Best,

CYA Staff

Contact Information

Please choose a Mentoring Program *

Mentoring to Manhood

Lily Sisterhood

Prefix

Mr.

Mrs.

Ms.

Dr.

Name

First Name

Last Name

Date Of Birth (MM/DD/YYYY) *

(mm/dd/yyyy)

Age *

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

How long have you lived at this address? *

Verify Email

Mobile Phone

Program Location *

Greenbelt Middle School

G. James Gholson Middle School

William Wirt Middle School

Bladensburg High School

CYA Community Based Program

Availability *

After School (between 3pm - 6pm)

Saturday (between 9am - 12pm)

Are you fluent in any additional languages? *

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 *

Where are you from or where did your grow up? *

Are you military/former military? *

Yes

Job Title *

Organization/Employer *

Job description *

Length of current employment? *

Can you be contacted at work? *

Criminal History Check

Have you ever been charged with any criminal offense? *

Yes

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

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

Additional Information

Please share your interest in becoming a youth mentor. Please include any personal qualities and relevant experiences that you'd like to share *

Please describe any experience you have being a mentor, volunteering with youth, or leading/developing others. *

How do you want to volunteer? *

Mentor

After School Tutor (Maryland)

After School Tutor (DC)

Other:

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

If "Other"

How did you learn about our mentor programs? *

Current Mentor or Volunteer

Parent

Newspaper/Ad

Website

Radio

Other

If "Other"

Please list your colleagues name and contact information

Volunteer Agreement *

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. * *

Yes

Signature *

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