Partnership 4 Kids Mentor Application

Group Mentoring Application
Mentor Basic Information

*Please note, Car insurance info. will be needed to complete this application.

* Legal First Name
Preferred First Name
* Legal Last Name
* Have you ever gone by a different last name?
If Yes, What was it?
* Date of Birth
* Social Security Number
Address
City
State
Zip code
Other cities and states lived in during the last 7 years
Home Phone
Cell phone
Work phone
Work phone ext.
* Email Address
Secondary Email
What is the best way to reach you?
Gender
Ethnicity (optional)
Race
Languages Spoken
If other:
How did you hear about Partnership 4 Kids?
Employer
Occupation
If in the military, do you expect to be deployed within the next 6 months? (optional)
Marital status
Photo Upload
No file is currently uploaded.
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Other Mentor Questions
What do you hope to gain from the mentoring experience?
What strengths do you bring to the mentoring process?
List other relevant experience (community involvement, hobbies, volunteer work, etc)
Mentor Preferences
Select Your Availability
Emergency Contact Info
Contact name
Contact phone
Contact relationship
References
Reference 1
* First Name
* Last Name
Relationship
How long have you known this person?
Would they be interested in volunteering with you?
Email Address
Phone
Reference 2
* First Name
* Last Name
Relationship
How long have you known this person?
Would they be interested in volunteering with you?
Email Address
Phone
Reference 3
* First Name
* Last Name
Relationship
How long have you known this person?
Would they be interested in volunteering with you?
Email Address
Phone
Proof of Car Insurance
Drivers License #
Issuing State
If you do not have a license, please check this box.
Type
Do you have any impairments that would cause a driving hazard?
Is there anything on your driving or criminal record that we should be aware of before processing your application please explain:

*Please note, Car insurance info. will be needed to complete this application.
* Name of Car Insurance Company
* Insurance Policy Expiration Date
* Policy number
If you do not have insurance, please check this box.
I have read and understand the contents of the following disclaimer.Click here to view the group mentor waiver text.

Equal Opportunity: Partnership 4 Kids is committed to full inclusion of students in our activities and services. Our organization does not and shall not discriminate based on religion, creed, color, sex, age, disability, national origin, marital status, sexual orientation and gender identity, legal use of consumable products, legal recreational activities, political activities, or any other protected class.
* Media Release SignatureClick here to view the Media Release text.
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Media Release Date