Partnership 4 Kids Mentor Application

Goal Buddy Application
Mentor Basic Information
* 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
* Have you lived in any other cities in the past 7 years?
If yes, please list cities and states
Home Phone
Cell phone
Work phone
Work phone ext.
* Email Address
Secondary Email
What is the best way to reach you?
Ethnicity (optional)
Languages Spoken
If other:
How did you hear about Partnership 4 Kids?
If in the military, do you expect to be deployed within the next 6 months? (optional)
Photo Upload
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Emergency Contact Info
Contact name
Contact phone
Contact relationship
Mentor Preferences
Volunteer Type
Is there a volunteer you'd prefer to work with?
Preferred Grade Levels (1-6)
Preferred School
Names and contact information of anyone you know who might be interested in volunteering
Driving and Criminal Record
Is there anything on your driving or criminal record that we should be aware of before processing your application please explain:
* I have read and understand the contents of the following disclaimer.Click here to view the Goal Buddy 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.

(Please use your cursor to sign in the box provided by clicking inside the box and holding down while dragging the cursor to form your signature)
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Media Release Date
* I have submitted the necessary information through the DHHS portal for the abuse registry checks.

Click here to complete the required DHHS screening. The screening must be completed following the instructions provided on the next page to be eligible to volunteer. Once you submit your screening, please check this box indicating that you have submitted the necessary information through the DHHS portal for the abuse registry checks.