MENTOR APPLICATION

MENTOR APPLICATION

If you are interested in becoming a mentor, please complete the following online form.

Detailed information such as addresses, phone numbers, etc is required for the on line application. If you prefer to submit your application by e-mail or fax, please email mentor@beamenntor.org or call 888/232-6368 x6175.

* Required field

You have selected the following project. Project Choice #1: Horizons
Last Name*
First Name*
Middle Name
Salutation
Birthdate*	(00/00/0000)
Gender*	M/F
Ethnicity*
Marital Status*	(Single, Married, Divorced)
Spouse/Partner's Name
Number of Children*
Ages of Children	Enter all ages that apply, separated by a dash (-). Ex: If you had 3 children ages 3,6,& 11, you would enter: 3-6-11.
Home Address*
City / State / Zip*
Have you lived in the state entered on the line above consecutively for the past 10 years?*	(Yes/No)
Home Phone*	(000-000-0000)
Cell Phone	(000-000-0000)
Email*
Enter New Password*
Confirm New Password*
Company*
President / CEO
Work Address
City / State / Zip
Work Phone*	(000-000-0000x00000)
Fax	(000-000-0000)
Current Occupation
Hours of Employment (9-5, 8-4, etc.)
Best time to contact you?*
May we call you at work?
What other languages do you speak?
How did you hear about the Mentor Project?
Have you ever been convicted of a crime, or are you currently released on bail, or on your own recognizance for any crime?*
Have you ever been cited for driving under the influence (DUI)?*

Do you object to our checking with appropriate authorities such as the Department of Justice, Federal Bureau of Investigation and the California Department of Motor Vehicles for matters of public record regarding your background and history?

Please list the names and complete addresses of three, unrelated references, one of which is a work reference. (References will have known you at least two years and are willing to discuss your character, reputation, and ethics.)

Reference 1*

Last Name
First Name
Middle Name
Salutation
Company Name (if any)
Address
City / State / Zip
Phone	(000-000-0000x00000)

Reference 2*

Last Name
First Name
Middle Name
Salutation
Company Name (if any)
Address
City / State / Zip
Phone	(000-000-0000x00000)

Reference 3*

Last Name
First Name
Middle Name
Salutation
Company Name (if any)
Address
City / State / Zip
Phone	(000-000-0000x00000)

Drivers License and Insurance Information*

State Issuing Driver License
Driver License Expiration Date	(00/00/0000)
Auto Insurance Carrier
Expiration Date	(00/00/0000)

Do you know someone else who might be interested in being a mentor?

Last Name
First Name
Middle Name
Company Name
Address
City / State / Zip
Phone	(000-000-0000x00000)

Be A Mentor Program does not discriminate on the basis of race, creed, educational level, physical disability, age, gender, sexual orientation, or marital status.

The above information is true to the best of my knowledge. I understand that I am not obligated, if called upon, to perform volunteer mentor services herein applied for, and that the agency is not obligated to assign, or actively seek to assign a student to me. I further agree to allow the staff of the Be A Mentor Program to elicit additional pertinent, personal information as part of the matching process.

In the event that I am chosen to mentor a youth, I agree to the commitment and to participate to the best of my ability. I will honor confidential information regarding my student. I will be free of the influence of alcohol or illegal drugs when with students on or off school grounds. I will inform the Project Coordinator of any changes in my address and/or phone numbers. I will inform the Project Coordinator in advance should I choose to stop volunteering.

I Accept I Do Not Accept

Please print application for your records before submitting

Be A Mentor Program
4588 Peralta Blvd., Suite 17
Fremont, CA 94536
Fax No.: (510) 795-6498

If you don't get a confirmation page after you've submitted the form, please resubmit it again or fax the form to us. Thank you.

kmorrison@beamentor.org

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