Mentor Application Form

Mentor Application Form

Lunch Buddy Program | Council on Adolescents
MENTOR APPLICATION
NAME
DATE OF BIRTH

MonthDayYear
Date
ADDRESS
CITY
STATE
ZIP CODE
CELL PHONE #
EMAIL
example@example.com
WORKPLACE (if applicable)
GENDER
ETHNICITY
LANGUAGES YOU SPEAK OTHER THAN ENGLISH
HIGHEST LEVEL OF EDUCATION YOU'VE RECEIVED
How did you hear about the lunch buddy program?
Have you mentored youth before?

YesNo
PREFERRED LEVEL OF COMMITMENT
OTHER RELEVANT EXPERIENCE (including volunteer work)
Why are you interested in being a mentor?
SCHOOL PREFERENCE (select all that apply)

Hickory City School DistrictNewton-Conover City School DistrictFoard Feeder DistrictMaiden Feeder DistrictSt. Stephen's Feeder DistrictBandy's Feeder DistrictBunker Hill Feeder DistrictCatawba Rosenwald (CREC)Challenger High SchoolOther
PLEASE INDICATE YOUR AVAILABILITY

If you are available to meet anytime between 10:30 AM and 1:00 PM, simply check the box. If your availability is more limited, please send me an email.

AVAILABLILITY

	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
AVAILABLE

SIGNATURE

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DATE

MonthDayYear
Date
To help us match you with a student, please indicate the hobbies and interests that you most enjoy!
SPORTS/ATHLETICS

BasketballSoccerBaseballFootballTennisSwimmingRunningBikingHikingDanceYogaMartial ArtsSkateboardingCheerleeding
ARTS & CREATIVITY

Drawing/PaintingCrafts/DIY ProjectsPhotographyGraphic DesignPlaying an InstrumentSingingActing/TheatreFashion DesignCreative WritingPoetryJewelry
ACADEMICS

ReadingWritingMathScienceHistoryGeographyLanguagesCoding/ProgrammingChessTriviaPuzzles
LIFE SKILLS

CookingBakingGardeningSewingLeadership
SOCIAL

VolunteeringCommunity ServiceSocial JusticeTravelChurchFaith/SpiritualityMentorship
TECHNOLOGY

Video GamesBoard GamesCard GamesYouTubeContent CreationMovies/TV ShowsSocial MediaRoboticsAnimationApp/Game DevelopmentPodcasting
HANDS-ON SKILLS

WoodworkingCar MechanicsConstruction/Building3D PrintingTrade Work
ANIMALS/NATURE

Pet CareWildlifeCampingFishingNature Walks
Should be Empty: