Mentor Application Changing the lives of our future SECTION ONE: GENERAL INFORMATION Name: * First Name Last Name How did you hear about Why I Am? Email Address: Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Phone Number: * (###) ### #### May we text this number? Yes No Best or preferred contact method Phone Email Other: SECTION TWO: I can commit to a minimum of 2 hours per week for a full calendar year from September through August. Yes No Why would you like to be a Why I Am mentor? * Date of Birth: * MM DD YYYY Gender/Identity Please check all that apply Male Female I identify as LGBTQ+ Other/not listed Prefer not to disclose Ethnicity Please check all that apply American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Pacific Islander White Prefer not to disclose Other: Emergency Contact Name * This person would only be contacted in the event of an emergency after no less than 3 attempts to contact you directly. First Name Last Name Emergency Contact Number * (###) ### #### Emergency Contact Relationship * Transportation I have a vehicle with valid insurance I'm utilizing other means of transportation Do you have a valid Driver's License? Yes No State Issued: Date Issued: MM DD YYYY Expiration Date: MM DD YYYY Best time to contact you Mon- Fri 8am-noon Mon-Fri noon-3pm Mon-Fri 3pm-6pm Sat 8am-noon Sat noon-3pm Sat 3pm-6pm Other as listed below: Occupation/Employer Length of Employment Highest level of completed education/Student status if you are currently attending, 'please indicate 'student' and the level below Degrees, Certificates or areas of study Marital Status Married Single Prefer not to say Other: for 'other' marital status: Do you have military experience? Yes No Prefer not to disclose Rate your level or interest or knowledge in the areas below Strongly Disagree is the lowest/least and Strongly Agree is the highest/more experienced Faith Strongly Disagree Disagree Neutral Agree Strongly Agree Outdoor activities Strongly Disagree Disagree Neutral Agree Strongly Agree Academics Strongly Disagree Disagree Neutral Agree Strongly Agree Athletics Strongly Disagree Disagree Neutral Agree Strongly Agree Life Skills (finances/independent living) Strongly Disagree Disagree Neutral Agree Strongly Agree Technology Strongly Disagree Disagree Neutral Agree Strongly Agree Mechanical Strongly Disagree Disagree Neutral Agree Strongly Agree Social Skills/Relationships Strongly Disagree Disagree Neutral Agree Strongly Agree Health/wellness Strongly Disagree Disagree Neutral Agree Strongly Agree Music/Production Strongly Disagree Disagree Neutral Agree Strongly Agree Favorite quote, scripture or encouraging word * *Why I Am conducts background checks through state and federal agencies for criminal records, child abuse and neglect proceedings Thank you!
