Mentor Application

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Mentor Information (Required)

Mentor First Name

Mentor Last Name

High School

Mentor Email

Mentor Cell Phone

Home Phone

Date of Birth

Graduation Year

Gender

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

State

WA

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

State

WA

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

State

WA

Postal Code

Community Service and Sports Information

List all extracurricular and service activities in which you have participated while in high school. (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? Have other members of you family done so? Please describe.

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, provide monthly information regarding your mentoring activities, and receive feedback regarding any difficulties during your participation in the mentoring program?

Yes

No

Are you willing to attend an initial mentor training session and then monthly meetings throughout the school year? Meeting attendance is required before being matched as well as throughout the duration of your match.

Yes

No

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

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