Community Mentor for YA Intake Form

Community Mentor Intake Form
Thank you for your interest in becoming a volunteer Community Mentor for the Levine Center To End Hate Youth Ambassador Program.

We encourage the participation of volunteers who support our
mission and are willing to contribute or invest in ways that perpetuate our programs. The information you provide through this form will help us pair you with a Youth Ambassador based on relevant professional and general life experience, background, interests, and availability.

The Levine Center To End Hate of the Jewish Federation of Greater Rochester reserves the right to perform background checks on any person interfacing with our staff and Youth Ambassadors.
Name*

PrefixFirst NameLast Name
date of birth*

MonthDayYear
current age:*
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Educational Background
College/School last attended*
Department/Field/Degree conferred
(optional) You can expand on your educational background here, if you wish:
Occupation

Please indicate if you have retired from the position you have listed.
Company*
Department/Position/Title*
Other relevant work experience (list approximate dates):
Youth work or support experience (including professional youth mentorship, teaching, youth counseling/mental health services, coaching, scout leadership, camp counselor, school support professional, tutoring), if any:
Do you have any volunteering experience? If yes, please describe.
Please list any community involvement, civic engagement, interests, or hobbies.
Community Mentorship: Opportunities for Corporate Sponsorship & Partners

We offer a variety of opportunities for corporate sponsors, including complementary training, complementary ticketing to our signature events, and numerous volunteer opportunities throughout the year. Please contact us for more information: info@endhateroc.org.
Will your Community Mentorship be a service project affiliated with your organization, company, or firm?*
If you answered 'yes,' please list your company's name below with the name and contact information for Community Outreach:
Have you ever been convicted of a felony or misdemeanor, been charged with aggravated assault of any kind, or appear on public record for harassment or other offenses?*
Please provide a photo of a state-issued identification (driver's license, military ID, passport). Your personal information will remain confidential and is for internal use only.

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Select your available days

MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays
From

Hour Minutes

AM/PM Option
To

Hour Minutes

AM/PM Option
Additional notes about your schedule
Statement of Honesty:

I affirm that the information I have provided above is accurate and submitted solely on behalf of myself.
Date

MonthDayYear
Date
Signature

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Should be Empty:

Community Mentor Intake Form

Educational Background

Occupation

Community Mentorship: Opportunities for Corporate Sponsorship & Partners