YPIA Mentor Application
Please fill out the information below and submit so that we may connect you to the opportunity within Young People in Action (YPIA) that best suits your skills and interests. We look forward to hearing from you!
Name:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
E-mail
*
Contact Phone
*
Work Phone
What is the best form of contact?
*
Email
Cell Phone
Work Phone
May we contact you at work?
Yes
No
Birth Date
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Non-Binary
Prefer to self-describe (enter below)
Prefer to not respond
Race/Ethnicity
*
African American/Black
Alaskan Native
Asian
European American/White
Latino/Hispanic
Middle Eastern
Mixed Race
Native American or
Northern African
Native Hawaiian or Pacific Islander
Prefer not to respond
Marital Status
*
Common Law
Divorced
Domestic Partner
Living w/ Significant Other
Married
Separated
Single
Unknown
Widowed
Prefer to not respond
Do you speak any other languages besides English?
*
Yes
No
What other languages?
Do you have a valid Driver's License?
*
Yes
No
What is your Driver's License number & State?
Have you ever mentored youth in the past?
Yes
No
Do you have an hour per week to mentor?
Yes
No
Do you have access to a car?
Yes
No
Which day of the week are you available for the interview and orientation?
Please Select
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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Emergency Contact Information
Please enter the information for an emergency contact. Should an emergency arise, this is the person that we would reach out concerning you. So please ensure that contact information is up to date.
Contact Name:
*
First Name
Last Name
Relationship to Applicant
*
Contact Phone
*
E-mail
*
example@example.com
Education and Employment History
Please enter your current education and employment history.
Are you currently in school?
*
Yes
No
Please list the name of the school(s) and your major(s):
Expected Date of Graduation
-
Month
-
Day
Year
Date
What is your highest level of education completed?
Some High School
High School Diploma/GED
Certificate Program
Associates Degree
Bachelors Degree
Masters Degree
Doctorate/PhD
Are you currently employed?
*
Yes
No
Please list any and all areas of interest and/or ability:
*
Mentoring
Activities Planning
Teaching
Marketing/Advertising
Administration
Other
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References
Please list three references (other than relatives) who have known you for at least a year and who can vouch for your character, reputation, and ethics. One should be someone who has known you in a professional capacity (i.e. an employer, teacher, supervisor, etc.).
Reference #1
Reference Name:
*
First Name
Last Name
Relationship
*
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Phone
*
E-mail
*
example@example.com
Reference #2
Reference Name:
*
First Name
Last Name
Relationship
*
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Phone
*
E-mail
*
example@example.com
Reference #3
Reference Name:
*
First Name
Last Name
Relationship
*
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Phone
*
E-mail
*
example@example.com
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Verification & Submission
Do you consent to a background check
Yes
No
How did you first hear about YPIA?
*
Friend/Family/Acquaintance
Search Engine (e.g. Google, Yahoo, etc.)
Social Media (e.g. Facebook, Instagram, etc.)
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YPIA Staff Member
Other
Please verify that you are human
*
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Submit
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