Mentors form | Champions Circle

Mentor application form

Date / Time

Date

Time

Personal information

Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Date of birth *

Email *

Phone *

Shirt size *

Occupation *

Employer information

Employer name

Address

Address Line 1

City

State

Zip Code

Employer phone number

Mentor information

1. Why do you want to become a mentor? *

2. As a mentor of Champion Circle what do you feel are your strengths (bilingual, math skills, previous relevant volunteer experience, etc.) you can bring to this program? *

3. Write a brief statement on why you have chosen to participate in Champion Circle mentor program. *

4. Please check the two statements below: *

I understand that the mentor program involves spending a minimum of one hour every week with an assigned student for the academic school year.
I understand that I will be required to complete the mentor program orientation and at least two mentors group meeting sessions during the year.

5. Within the past 10 years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance? *

Yes
No

6. Are you under current indictment or has a district/county attorney accepted an official complaint for any of the offenses in question? *

Yes
No

7. If the answer is YES to questions 5 or 6, please explain below:

8. Educational Background. (check all that apply):

9. What days of the week are you available to volunteer? (Check all that apply): *

10. What is the best time for you to volunteer? (Check all that apply): *

Personal references

Please list two references (you may include family members, personal friend and/or work reference):

Reference One *

First

Last

Address

Address Line 1

City

State

Zip Code

Reference Two *

First

Last

Address

Address Line 1

City

State

Zip Code

DISCLAIMER AND ACKNOWLEDGEMENT

In completing this application to be a mentor, I understand that GADF routinely performs background checks of all volunteers for the position of mentors for which I am applying. I have the understanding that by signing below I am giving GADF permission to perform a background check. I certify to the best of my knowledge that the information provided on this application is true and accurate.

Signature *

Mentor application form

Personal information

Employer information

Mentor information

Personal references

DISCLAIMER AND ACKNOWLEDGEMENT

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