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Mentor Application
Contact Information
Name
*
First Name
Last Name
Email
*
Verify Email
*
Phone
*
Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
If in high school, please list school and grade.
*
Briefly describe yourself, including hobbies
*
List any special interests or skills you would like to share with a mentee
*
I would like to be matched with a mentee who (list age, gender, etc. of mentee; if you have no preference write 'open'):
*
Days and times I can meet with a mentee
*
References
Please list three different references along with contact phone numbers for each
Reference #1
*
Phone Number
*
Reference #2
*
Phone Number
*
Reference #3
*
Phone Number
*
I agree to release my phone number to my mentee so we may communicate directly about meeting changes
Yes
No
I would prefer to go through The Collaborative Staff to communicate about meeting changes
*
Yes
No
Have you ever been convicted of a crime?
*
Yes (If yes, please explain in the comment box at the bottom)
No
Have you ever been placed on probation or parole?
*
Yes (If yes, please explain in the comment box at the bottom)
No
Is there someone you would like to refer as a potential mentor volunteer?
If yes, please list name and best way to contact them.
I give The Collaborative Mentor Program permission to use photos of me in press releases and/or newsletters
Yes
No
Other comments, questions, or concerns