one-to-one mentor application – Annapolis and Anne Arundel County Scholarship Trust

Name

First

Last

Gender

Male
Female

Ethnicity

Address

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Contact Number

Home Phone
Cell Phone
Work Phone

Phone

Employer

Length of Employment

Job Title

May we contact you at work?

Education completed:

High School
Other

2 year degree in:

School

4 year degree in:

School

Advanced degree in:

School

Additional Information

How was the Program brought to your attention?

What motivated you to apply to the Program?

Will you be able to meet with a student at least once a month during the school year?

What are your hobbies, special skills, or other interests?

What do you like to do in your leisure?

What other affiliations (e.g., service or volunteer organizations) do you have?

What do you hope to gain from the mentoring experience?

What do you hope your mentee gains from the mentoring experience?

Do you have prior mentor experience?

If yes, please explain: (Program Name & Dates)

How many students would you like to mentor?

Mentors often have a particular set of experiences to share, please help us achieve the best possible match by specifying if you would like to mentor a student from a specific cultural background (if available)?

If yes, what cultural background?

Is there a particular student you would like to mentor?

Student Name

First

Last

Student High School

Why?

Are you willing to have the board conduct a background check on you, including fingerprints?

List three people (non family members) who can serve as character references for you.

Name *

First

Last

Relationship

Years Known

Selected Value: 0

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Reference 2

Name *

First

Last

Relationship

Years Known

Selected Value: 0

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Reference 3

Name *

First

Last

Relationship

Years Known

Selected Value: 0

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

ACCEPTANCE OF TERMS AND CONDITIONS:

I certify that the information I have supplied is correct to the best of my knowledge. I grant permission for you to contact the references provided. I also understand and agree to the duties and requirements described in the Volunteer Duties and Requirements.

Signature

Date