Mentor Application Form

Mentor Application Form

Please fill out the following application to become a mentor with MENAC, Inc. We value your commitment to mentoring students in Eastern North Carolina. All fields are required unless specified otherwise.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Residential Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth*

MonthDayYear
Date
Current Occupation*
Brief Description of Your Job Responsibilities*
Why do you want to be a mentor?*
Availability for Mentoring*

Weekday morningsWeekday afternoons
Gender*

MaleFemale
Ethnicity*

African AmericanAsianHispanicNative AmericanWhiteOther
Education*

GEDHigh School DiplomaAssociate Degree (AA)Bachelors Degree (BA)Masters Degree (MA)Doctoral Degree (PhD)
Martial Status*

SingleMarriedDivorcedWidowed
Number of Children*

1234Other
Describe any previous mentoring, teaching, or volunteer experience
Background Check Authorization*

I authorize MENAC, Inc. to conduct a background check as part of the screening process.
Volunteer Confidentiality - Any volunteer who is responsible for the misuse of confidential information is subject to immediate dismissal. Violations of this may result in criminal and/or civil action*

I have read and understand MENAC, Inc. policy.
Character References (please provide three references with contact information)*
Future Goals
New Mentor Signature

Clear
Should be Empty: