Mentor

Personal information

First name *

Middle name *

Last name *

Date of birth *

Gender *MaleFemale

Ethnicity *

Mailing address

Street address *

Apartment, suite, etc. (optional)

City *

State *

ZIP code *

Email address *

Preferred contact number *

Home phone

Work phone

Cell phone

Employment

Employer *

Job title *

Length of employment (months) *

May we contact you at work? *YesNo

Education

Highest level of education completed *

If other, please specify

Degree(s) and field of study

Motivation and availability

How was the program brought to your attention? *

Can you meet with a student at least once a month during the school year? *YesNo

What motivated you to apply to the program?

What are your hobbies, special skills or other interests? *

What do you like to do in your leisure time?

What other affiliations do you have? (service or volunteer organizations)

What do you hope to gain from the mentoring experience?

What do you hope your mentee gains from the mentoring experience?

Why would you like to mentor?

Mentoring preferences

Do you have prior mentoring experience? *YesNo

How many students would you like to mentor? *

If you have prior experience, please explain

Would you like to mentor a student from a specific cultural background?YesNo

If yes, which background?

Is there a particular student you would like to mentor?YesNo

If yes, who?

Are you willing to have a background check, including fingerprints? *YesNo

Please provide three character references. They must not be family members.

First character reference

First name *

Last name *

Relationship *

Years known *

Mailing address

Street address *

City *

State *

ZIP code *

Phone *

Email *

Second character reference

First name *

Last name *

Relationship *

Years known *

Mailing address

Street address *

City *

State *

ZIP code *

Phone *

Email *

Third character reference

First name *

Last name *

Relationship *

Years known *

Mailing address

Street address *

City *

State *

ZIP code *

Phone *

Email *

I certify that the information contained in this application is correct to the best of my knowledge. I give Young Men of Distinction Inc. permission to contact the references listed above, and I agree to the Volunteer Duties and Requirements of the program.

Signature – type your full name *

Date *

Signature image (optional)

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Only if you prefer to upload a signed copy. Typing your name above is sufficient.

What we ask of mentors

What the application covers

Apply to mentor