Mentor Application
Section 1: Applicant Information
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Nonbinary
Male Trans
Female Trans
Prefer Not to Say
Race/ Ethnicity
*
Asian - Filipino
Asian - Japanese
Asian - Chinese
Asian - Indian
Asian - Korean
Asian - Other
Black or African American
Hispanic - Cuban
Hispanic - Mexican,Mexican American,Chicano
Hispanic - Other Latinx or Spanish origin
Hispanic - Puerto Rican
Middle Eastern or North African
Pacific Islander - Chamorro
Pacific Islander - Native Hawaiian
Pacific Islander - Samoan
Pacific Islander - Other
White or Caucasian
Other
Relationship Status:
*
Married
Single
Divorced/ Separated
Domestic Partner
Widowed
Personal Phone Number
*
Please enter a valid phone number.
Personal Email
*
example@example.com
Work Email
example@example.com
Work Phone Number
Please enter a valid phone number.
Preferred Method of Contact
*
Personal Phone Number
Personal Email
Work Phone Number
Work Email
Preferred Time to Contact You
*
Morning (8 am-11 am)
Afternoon (12 pm- 5 pm)
Evening (6 pm- 8 pm)
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you possess a current driver's license and current insurance?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Do you have plans to move out of Los Angeles county in the next 18 months?
*
Yes
No
Not at the moment
Emergency Contact
Name
*
First Name
Last Name
Personal Phone Number
*
Please enter a valid phone number.
Relationship To You:
*
Adult Child
Parent
Sibling
Other Family Relative
Partner
Co-Worker
Other
Section 2: Educational Background
School Name (Most Recent)
*
Grade Level/Degree
*
Year Graduated
*
Section 3: Goals and Aspirations
What are your short-term career or personal goals? (Please list 2-3 goals)
*
What are your long-term career or personal aspirations?
*
Describe any challenges you have faced/ are facing in achieving your goals.
*
Section 4: Mentorship Expectations
Have you previously been a mentor here or anywhere else?
*
Please Select
Yes (SoLa Foundation, Big Brother Big Sister, other)
No
Why do you want to be a mentor?
*
What are some unique qualities or skills that you possess that you believe will help be an amazing mentor?
*
What specific areas do you hope to give guidance on? (Check all that apply)
*
Please Select
Academic Support
Career Planning
Personal Development
Networking
Goal Setting
Other (Please specify):
If you chose "other" please specify below:
What qualities do you look for in a mentee?
*
Are you willing to spend a total of 3-5 hours with your mentee at least three times a month for our Community-Based Program? (If not, please look at other programs on our website.)
*
Yes
No
Are you willing to make a one-year commitment to the program?
*
Yes
No
Do you have any concerns about your ability to fulfill a minimum of 1-year commitment requirement to go on outings two/ three times a month for a minimum of 3-5 hrs total?
*
Do you anticipate any significant life changes over the next year or have you had any this past year? (ie. job or schedule changes, moving, new family member, etc.)
*
Are you available during weekends?
*
Yes
No
Have you ever been involved with SoLa Impact in any capacity other than a mentor or volunteer?
*
Yes
No
Have you ever been denied acceptance or released from service as a volunteer or employee or Mentorship Program for another youth-serving organization?
*
Yes
No
Employment History (Last/ Current Company)
Company Name
*
Position/Title
*
Duration (number of months)
*
What is your role and responsibilities in that company?
*
References
Please provide at least three references below: Eligible reference pool: Those within your professional network. Current or former employees or co-workers you have known for at least one year or someone from your school if you are a student. Family and or Friends.
Name
*
First Name
Last Name
Relationship
*
Company Name
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Name
*
First Name
Last Name
Relationship
*
Company Name
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Name
*
First Name
Last Name
Relationship
*
Company Name
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Acknowledgment
Check all boxes to show you acknowledge each statement.
*
I hereby certify that all information I provided in this document is accurate and true to the best of my knowledge
I understand that data collected from this form will be used for recruitment and evaluation purposes only. All data will be strictly confidential.
Submit
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