Name

Phone

Email

Date of Birth

Address

City

State

Zipcode

How many years have you resided at the above address?

If less than five years, previous address (please include city and state if not Tampa)

Occupation

Employer *If not currently working please note most recent employer

Supervisor’s name and phone number. *If not currently working please note most recent supervisor

What are your hours?

Highest level of education completed

Gender Gender Female Male Other

Marital Status Marital Status Single Married Widowed Divorced Separated

Spouse’s Name

Will spouse be involved in program? Will spouse be involved in program? Yes No

Highest level of education for spouse

Do you have children? Do you have children? yes no

Childrens' names and ages

I would like to be a mentor in: I would like to be a mentor in: Hillsborough County Pinellas County

Do you have a preference regarding the gender of your student?

Special skills, languages or hobbies

Do you own a car? Do you own a car? Yes No

Do you have prior mentoring experience? Do you have prior mentoring experience? Yes No

If so, with whom?

List any previous experience you have with youth or other volunteer activities

Who referred you to this program?

Reference 1: Name, Email, & Phone number

Reference 2: Name, Email, & Phone Number

Reference 3: Name, Email & Phone Number

Have you ever been convicted, pled no contest, or had adjudication withheld in a criminal offense, felony, misdemeanor or are there any criminal charges now pending against you other than a minor traffic violation? Have you ever been convicted, pled no contest, or had adjudication withheld in a criminal offense, felony, misdemeanor or are there any criminal charges now pending against you other than a minor traffic violation? No Yes

If convicted of a felony, please explain circumstances

I certify that all information on this application is true and complete. Any misrepresentation, omission or incorrect statement of facts is cause for immediate dismissal of me as a mentor. I also understand that any other person in contact with my mentoring family, including family members, will need to complete a mentor application prior to contact with the family. Youths will not be fingerprinted. I certify that all information on this application is true and complete. Any misrepresentation, omission or incorrect statement of facts is cause for immediate dismissal of me as a mentor. I also understand that any other person in contact with my mentoring family, including family members, will need to complete a mentor application prior to contact with the family. Youths will not be fingerprinted. Yes

Date