Mentor Application
Name: Dr./Mr./Mrs./Ms. _____________________________ Age: ________
Mailing Address: ________________________________________________________
City: __________________ State: _______ Zip: ___________
Phone (H): _____-______ Phone (W): _____-______ E-mail: _______________
Employer: _________________________ Occupation: ______________________
Education (check highest level):
High school: ___ Associate Degree: ____ Bachelor's: ____ Master's: ____ Doctorate: ____
Community Involvement: _____________________________________________________________
______________________________________________________________________
Experiences In Working With Children: _________________________________________________
______________________________________________________________________
Interests (please check)
| Travel: ___ | Crafts: ___ | Shopping: ____ |
| Reading: ____ | Art: ____ | Cooking: ____ |
| Walking/Hiking: ____ | History: ____ | Gardening: ____ |
| Nature: ____ | Science: ____ | Collecting: ____ |
| Music: ____ | Computer: ____ |
Sports (specify): _________________________________________________________________________
Other: _________________________________________________________________________________
Foreign Language: _______________________________________________________________
| Preferences: | Book Buddy
(K-3) : ____ |
Peer Pals
(4th-5th): ____ |
Middle Ground(6th-8th):
____ |
School preference (if desired): ______________________________________________________
Signature: __________________________________
Date: ______/_______/_________