Partnership 4 Kids Mentor 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?

Gender

Ethnicity (optional)

Race

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)

Employer

Occupation

Photo Upload

No file is currently uploaded.

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Emergency Contact Info

Contact name

Contact phone

Contact relationship

Mentor Preferences

Volunteer Type

Availability

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	You are using a device that has limited capabilities in website editing. To have access to the full options, please use another device.

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:	You are using a device that has limited capabilities in website editing. To have access to the full options, please use another device.

* 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)	Clear

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.

* 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.