Mentor Application

Please provide the following contact information:

FIRST NAME
MIDDLE INITIAL
LAST NAME
STREET ADDRESS
ADDRESS (cont.)
CITY
STATE
ZIP/POSTAL CODE
CELL PHONE
HOME PHONE
E-MAIL
Best time to contact you

Please identify and describe yourself:

Date of Birth

Sex        Male Female

          Ethnicity Please Select One: Chinese Japanese Southeast Asian Filipino African American Caucasian Latino Native American Muti-racial Other

Do you speak any languages other than English?        Yes    No

                       If yes, which languages?   

 Are you employed ?    Yes    No

                       If yes, where? 

                       What is your title? 
 

How did you hear about the BRIGHT Families Project?            Select One: Friend/Family BRIGHT Families Presentation Craigslist Volunteer San Diego Volunteer Match Internet Flyer Radio/TV Ad Newspaper Ad Other

Please describe/list your career fields or interests (i.e. business, social services, homemaker, science, etc.)

Please describe your educational background:

Please list any previous experience with youth, teen pregnancy, parenting or volunteering:

Please list any activities or hobbies that interest you:

Please list any children you have (names, ages, genders):

Name     Age          Gender Select One: Male Female

Name     Age          Gender Select One: Male Female

 

Do you currently have an active CPS case?  Select One: Yes No Not Sure

              If yes, when will it close?

Have you ever obtained security clearance through the Dept. of Justice?   Select One: Yes No Not Sure

            If yes, when?
 

Please list any preferences for mentee match (e.g., age, population, situation, interests)

Why are you interested in becoming a mentor?

Please list three (3) personal references who have known you for at least two years:
        (Exclude family members; at least one reference should be an employer or teacher)

1. Reference Name

    Phone Number

    Email or Mailing Address

 

2. Reference Name

    Phone Number

    Email or Mailing Address

 

3. Reference Name

    Phone Number

    Email or Mailing Address

 

I am willing to commit to being a mentor for at least 4 hours per month for six months, attend a Clinic Tour, and submit Monthly Report Forms.  I understand I will be trained on the material to be used with my mentee and will follow the guidelines regarding those materials. I also understand that information about my mentee is confidential and will not be used for any other purpose or shared with anyone without permission unless mandated by law*. I agree to have a background check for Criminal Justice clearance.

I hereby agree to hold harmless the regents of the University of California, its officers, agents, and employees, and The BRIGHT Families Project from any liability resulting from or arising in connection with participation in the BRIGHT families project.

  Select One: Agree Disagree

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