G-CODE Mentor Application

G-CODE

Mentor Application
Full Name
Date Of Birth
Address

Current Street Address

Street Address Line 2

CityState / Province

ZIP
Phone Number
Email
example@example.com
Preferred Contact Method.

CellEmail
If You Have Lived At The Above Address For Less Than 36 Months:

Please provide prior address.
Prior Street Address
City
ZIP
Do You Have A Valid Drivers License? If Yes, Please Submit Proof Below.

YesNo
Please upload a Clear Photo or File of Valid Drivers License.

Cancelof
Do You Have A Valid Car Insurance Policy? If Yes, Please Submit Proof Below.

YesNo
Please upload a Clear Photo or File of Valid Car Insurance Policy.

Cancelof
"As part of the G-CODE mentorship program, we require a valid copy of your driver's license and car insurance policy to ensure the safety and well-being of all participants. These documents confirm that any transportation provided to mentees is properly insured and compliant with legal requirements. This step helps us create a secure environment for both mentors and mentees and aligns with our liability protocols. Rest assured, your personal information will be kept confidential and used only for verification purposes."
May we use program event photos of you in our media? This is optional demographic information that helps us in reporting for funding.

YesNo
Your Race and/or Culture (check all that apply):

African AmericanCaucasianAsianHispanicHaitianNative American or Pacific IslanderOther (Please Specify)
How Did You Hear About GCODE?
Please explain why you want to be a mentor
What other volunteer experience have you had?
Have You Worked With Youth In Any Other Capacity? If yes, Please Explain.
Please Provide 2 References & Please Do Not Include Any Family Members.
Name
Phone
Email
example@example.com
Relationship
Name
Phone
Email
example@example.com
Relationship
ACKNOWLEDGEMENT, STATEMENT AND RELEASE
I, the undersigned, hereby state that if accepted as a mentor, I agree to abide by the rules and regulations of G-CODE. I understand the program involves spending minimal one hour each week with assigned mentee in person or via phone.

I have read and understand the above written G-CODE release

Further, I hereby fully release, discharge and hold harmless G-CODE and all of the foregoing's employees, officers, directors, and coordinators from any and all liability, claims, causes of action, costs, and expenses which may be or may at any time hereafter become attributable to my participation in G-CODE.
Signature

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G-CODE

If You Have Lived At The Above Address For Less Than 36 Months:

Please Provide 2 References & Please Do Not Include Any Family Members.

ACKNOWLEDGEMENT, STATEMENT AND RELEASE