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 #
Format: (000) 000-0000.
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?
PREFERRED LEVEL OF COMMITMENT
OTHER RELEVANT EXPERIENCE (including volunteer work)
Why are you interested in being a mentor?
SCHOOL PREFERENCE (select all that apply)

Other
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

Rows	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
AVAILABLE

SIGNATURE
DATE

MonthDayYear
Date
To help us match you with a student, please indicate the hobbies and interests that you most enjoy!
SPORTS/ATHLETICS
ARTS & CREATIVITY
ACADEMICS
LIFE SKILLS
SOCIAL
TECHNOLOGY
HANDS-ON SKILLS
ANIMALS/NATURE
Should be Empty: