Mentor Information (Required) Mentor First Name Mentor Last Name High SchoolPlease select... Eastlake High School, Sammamish Skyline High School, Sammamish Newport High School, Bellevue Eastside Catholic High School, Sammamish Redmond High School, Redmond Mercer Island High School, Mercer Island Liberty High School, Renton Lake Washington High School, Kirkland Issaquah High School, Issaquah Bellevue High School, Bellevue Juanita High School, Kirkland Mentor Email Mentor Cell Phone Home Phone Date of Birth Graduation YearPlease select... 2019 2020 2021 GenderPlease select... Male Female Other Race of mentor White/Caucasion Alaska Native African American Latino American/Hispanic Native Hawaiian/Pacific Islander American Indian Asian Other Prefer not to answer Mentor Home Address Street City StateWA Postal Code Parent/Guardian #1 (Required) First Name Last Name Email Cell Phone Company Occupation Home Address Same as above Different address Parent / Guardian # 1Address Street City StateWA Postal Code Parent/Guardian # 2 (Required) First Name Last Name Email Cell Phone Company Occupation Home Address Same as above Different address Parent / Guardian # 2 Address Street City StateWA Postal Code Community Service and Sports Information List all extracurricular and service activities in which you have participated while in high school. Activities both on-campus and in the community List all high school sports (competitive, not intramural) in which you have participated Additional Information Describe three (3) reasons you want to be Athletes for Kids mentor? Have you worked with children (or adults) who have disabilities or special needs? Please describe. Also, let us know if other members of you family have worked with disabilities. Are you willing to be assigned to a young child who may have a disability until you graduate from high school? Yes No You will receive training before being assigned to a young child. You will be expected to spend at least 6-8 hours each month with that child. Are you willing to communicate regularly and openly with program staff? Yes No This includes providing monthly information regarding your mentoring activities, and receive feedback regarding any difficulties during your participation in the mentoring program. Are you willing to attend an initial mentor training session and then monthly meetings throughout the school year? Yes No Meeting attendance is required before being matched as well as throughout the duration of your match. Please indicate if you are willing and able to keep personal information about your match confidential? Yes No Would we have any concerns if we looked at your Facebook, Twitter, Instagram, Pinterest, YouTube or if we googled you? Yes No Confidential Information Have you ever been arrested for, charged with, or convicted of a felony or misdemeanor? Yes No Have you ever been involved in disciplinary action such as suspension from school for any reason? If yes, please give the date(s), school, and circumstances. Goals By becoming a mentor I hope to gain (check all that apply) Leadership Skills Character Development Community Service Hours Friendship Compassion Patience Community Engagement Please provide three adult references for your recommendation. Reference # 1 Name of a teacher in your high school Email or Phone Number Reference # 2 Name of one of your athletic coaches Phone number or email Reference # 3 Name of one other adult (e.g. friend or neighbor, outside of your immediate family whom we can contact for a character reference.) Phone number or email reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Need assistance with this form?
