Sample Mentor Application

Complete the form below, attaching additional pages if necessary.

Name:
Postal Address:
City:
State:
Zip Code:
Home Phone:
Email:

1. Are you currently a college student? If yes, what institution do you attend? What is your year in school and field(s) of study?
2. What is your occupation? Are you currently employed? If so, who is your employer? What is your position?
3. Please list any postsecondary degrees you have completed.
4. Have you ever been a mentor before? If so, please describe your experience(s).
5. Have you had personal or professional experiences with disabilities that you could share with participants? If yes, please describe.
6. Do you have any hobbies or special skills that you think will benefit our participants?
7. Do you speak a language other than English? If yes, please list.
8. Mentoring a young person is a big responsibility and can change the lives of both the mentor and the protégé. What do you hope to gain from the experience? What do you hope the protégé will gain?

List names and contact information for three references.

I have read and agree to the expectations listed for mentors as outlined in the Guidelines for Mentors publication. I authorize you to contact my references and process a background check.

Signature: ___________________________________________________