HIGH SCHOOL MENTOR APPLICATION

Save & Return

Use an account to return to saved work.

First Name *

Last Name *

Gender: *

Date of Birth * +

Home Address *

City/State/Zip: *

Email Address: *

Cell Phone Number: *

Home Phone Number: *

What School Do You Attend? *

Whitesville Central School District

Other Other

Grade *

Parent/Guardian Name: *

Parent/Guardian Home Phone Number: *

Parent/Guardian Cell Phone Number: *

Emergency Contact Name: *

Relationship to Mentor: *

Emergency Contact Phone Number: *

What is the Mentor's Living Situation? *

Child's Race/Ethnicity: *

Parent/Guardian Place of Employment:

Parent/Guardian Work Phone:

May we contact them at this number?

Yes

No

The income information listed below is kept confidential and is used anonymously for grant purposes only.

Does Parent/Guardian Receive Income Assistance? *

Yes

No

Does Anyone in Your Family Receive Free or Reduced Lunch? *

Yes/Free

Yes/Reduced

No

Please Check Your Estimated Household Income: *

Is your family considered to be low income? *

Yes

No

Not sure

Why are you interested in becoming a mentor? *

Briefly explain the personal qualities that you believe would make you a good mentor. *

REFERENCES

Please include the following information for two references. References can include a teacher, school counselor, adult employer, or adult co-worker.

REFERENCE #1

Reference Name: *

Relation to Mentor: *

Reference Daytime Telephone Number: *

Reference Email Address: *

REFERENCE #2

Reference Name: *

Relation to Mentor: *

Reference Daytime Telephone Number: *

Reference Email Address: *

I understand that:

1. The references I listed may be contacted by mail, telephone, or email;

2. I am in no way obligated to perform any volunteer services;

3. Youth Mentoring of the Southern Tier is not obligated to match me with a youthl and

4. As part of the enrollment process, I will be asked to provide additional personal information prior to any recommendations being made for assignment.

Signature *

clear

Date *