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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 our program manager Alicia Hargrove at, and she will be happy to assist. We look forward to working with you!


CYA Mentoring Staff

Contact Information


Educational and Professional Background

Criminal History Check

Additional Information

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:

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