2022-2023 Mentor Application and Profile Form

Personal Information
Name * *

First Name Last Name
Gender * *

Male Female Other
Address where you currently reside * *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Email * *
Cell Phone Number * *

Area Code Phone Number
Birthday * *

Month Day Year
Country of origin * *
School/Professional Information
I consider myself a:* *

College Student Recent Graduate/Young Professional University faculty/staff Working Professional Retired Professional Other
What is the highest level of education you've received? * *
College/University you attended * *
What is your latest Major or degree? * *
Professional/Job Title * *
Are you affiliated with an ERG or BRG? If so, please list name below. If not, please write N/A. * *
Volunteer/Mentor Information
Please attach your most current resume and reference list. * *

Cancel of
Why do you want to be a mentor? * *
Do you have previous volunteer experience, or experience working with youth? If so, please specify. * *
Please describe your strengths as a mentor for Latinx youth. How can your experience (personal, professional, or both) help guide or support a middle or high school student? * *
How would you describe your personality/interests? Select all that apply: * *

Outgoing or Sociable Sports Fan Introverted or Reserved Lover of learning new things Thrill Seeker Health-Conscious Foodie/Home Chef Athletic Nature Enthusiast Pet Person Artistic/Maker
Which similarities do you seek in a mentee? Select all that apply: * *

Characteristics/Personality type Common interests Family dynamics/Background Career aspirations
Please indicate your mentee grade preference (check all that apply): * *

6th 7th 8th 9th 10th 11th 12th
Our mentees are students at the schools listed below. Please select the site(s) most favorable to you. While we will try to accommodate your preference when matching you, we cannot guarantee your request. *

Sequoyah Middle School Cross Keys High School Lilburn Middle School Meadowcreek High School Tri-Cities High School Chamblee Charter High School Dalton Academy McClure High school No preference-- I'm open to all sites!
How did you hear about the Latino Youth Leadership Academy and its mentorship program? *
Criminal HistoryBy completing this application, you agree to immediately notify the Latin American Association should there be a change of circumstances that affects the accuracy of your answers in the following section, between the date you submit your application and your first day of mentorship.
Have you ever been convicted of or adjudicated to be guilty of a violent felony offense, required to register as a sex offender by any legal authority in the U.S. or any other country, or are any charges involving a violent felony or sex offense pending against you at this time? * *

No Yes. If you answer yes, complete the next question.
List all the offenses and/or pending charges, the date of each offense/charge, and the date of each conviction/adjudication. Also, describe the circumstances surrounding each offense/charge and if you wish, you may provide a statement as to why you believe this information should not be a cause for concern about the safety of the community. *
By checking the boxes below, I certify that the statements I have made in this application and include in subsequent correspondence are/will be complete and true to the best of my knowledge. I acknowledge that it is my responsibility to be aware of all pertinent application requirements and that I have read and understand all application instructions. I understand that failure to disclose complete and accurate information, or failure to submit all required application information and official documents including those outlined in the background check may result in the withdrawal or dismissal of mentor program or other corrective actions as necessary. Please note that applicants may be required to sign a driver affidavit and provide proof of current driver’s license and registration.

Personal Information

	Completed
Personal Information
School/Professional Information
Resume & Reference List
Volunteer/Mentor Information
Criminal History
I hereby certify that the statements found above are true and complete
I acknowledge that this application does not guarantee a position as a mentor

I acknowledge and agree that I must attend mandatory training provided for mentors. Training dates will be sent to mentors via email closer to the date. * *

Yes, I acknowledge and agree to these terms.
I acknowledge that, if selected to become a mentor, I must complete an online background check form. This background check will be paid for by the Latin American Association after I submit my information. * *

Yes, I acknowledge and agree to these terms.
New mentor cohorts will be notified by LAA youth team member. Please direct questions to landino@thelaa.org
Email
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Personal Information

School/Professional Information

Volunteer/Mentor Information

Criminal HistoryBy completing this application, you agree to immediately notify the Latin American Association should there be a change of circumstances that affects the accuracy of your answers in the following section, between the date you submit your application and your first day of mentorship.

New mentor cohorts will be notified by LAA youth team member. Please direct questions to landino@thelaa.org

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