KidPOWER Mentor Application 2022-2023

KidPOWER Mentor Application

All information on this form is kept confidential. The information you provide may be used to match you with your mentee. Please complete the form in its entirety.
Name:*

First NameMiddle InitialLast Name
Phone Number*
Personal Email Address:*
Please do not provide a school email address
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date:*

MonthDayYear
Gender
Are you a student enrolled at Trevecca?

YesNo
Estimated Graduation Date:
Current Employer:
How did you hear about KidPOWER mentoring?

References

Please provide the names and email addresses of three individuals who know you well and can attest to your character, skill and dependability.
Please do not list more than one relative as a reference.
REFERENCE #1:*

First NameLast Name
Email Address:*
How do you know this person? *
REFERENCE #2:

First NameLast Name
Email Address:*
How do you know this person? *
Before submitting the application, please read the following statement carefully and sign below:

"I swear or affirm I provided accurate and complete responses to all information requested herein. I give my consent to CrossBRIDGE to confirm all information provided."
e-Signature:*
Today's Date:

MonthDayYear
Should be Empty: