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Name: _______________________________________________________________________ (last) (first) (middle)
Address: _____________________________________________________________________
_____________________________________________________________________________
Telephone #: ______________________________E-mail: ________________________
Birth date: __________________Age: ________ Sex: M F
_____________________________________________________________________________
Do you have children? _____Number ____ Do you have grandchildren? _____ Number____
Have you had any experience working with middle school age students (10-14 yrs?)________ If yes what kind was that? Taking care of family or neighborhood children? _________________________ Working in a school or recreation center? ______________________________ Scouting? ________________________________________________________ Other? (please describe)_____________________________________________
What are your hobbies, interests or special abilities? _____________________________________________________________________________
_____________________________________________________________________________
How would you rate you general health?
Excellent Good Fair Poor
Any limitations? ___________________________________________________
Have you had employment experiences? Yes No
If yes what kind of jobs did you have and how long did you do them? Please begin with most recent.
Job Where Years ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Why are you interested in becoming a mentor? _____________________________________
_____________________________________________________________________________
Are you willing to participate with other mentors in group mentoring activities? Yes No
Would you like to volunteer, if needed, for chaperoning trips, or helping with certain aspects of the program through your background/strengths? Yes No
Can you list three (3) activities that you enjoy doing yourself? 1) _______________________________
2.) _______________________________ 3.) _________________________________
Would you be willing to be a site leader at one of the Community Outreach places where the teens do Community Service, or a leader for an outing such as bowling, fishing or going to the park? Yes No
Please list 3 references, other than a relative. If possible, one should be work related
1. Name _____________________________________________ Phone ______________
Address ________________________________________________________________
_________________________________________________________________
2. Name _____________________________________________ Phone ______________
Address ________________________________________________________________
_________________________________________________________________
3. Name _____________________________________________ Phone ______________
Address ________________________________________________________________
_________________________________________________________________
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