Mentor Application Page 2 - College Mentors

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Mentor Application

College Mentors is looking for enthusiastic individuals whose compassion, integrity, and diverse perspectives will bring enrichment and inspiration to the lives of children.

Chapter: Ball State University

Choose an activity day (if applicable):

(Hold the shift key to select multiple)

First Name: Last Name:

Email Address:

Password:

(at least 6 characters)

Address During School Year:

Apt/Unit #

City:

Country:

State:

(?)

Zip Code:

County:

If foreign address, please list your state or province plus other info:

Campus Phone (including area code):

Cell Phone (including area code):

Birth Date: - -

I have lived outside of the state of Indiana in the past five years Yes No

Approximate Graduation Date:

Are you interested in learning more about College Mentors for Kids leadership opportunities? Yes No

Are you CPR/First Aid certified? Yes No

Do you speak a language other than English - well enough to be paired with a child who speaks that language? Yes No
What language do you speak?

Please answer the following questions in short essay/paragraph form:

1. Extracurricular Activities:
a. Please list past and current activities, not limited to college. (Clubs, Hobbies, Volunteerism, Leadership positions, etc.) (max. 2500 characters)
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b. Please distinguish those in which you are currently involved. (max. 2500 characters)
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2. Why do you feel you would be a good mentor to a child? (max. 2500 characters)
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3. What element of your background would make you a unique mentor?(max. 2500 characters)
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4."At risk" youth are in need of much support and reliability in their schedules, how do you feel that you are prepared to make this kind of a commitment to a child? (max. 2500 characters)
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5. Please list two references who can attest to your character and reliability.

Reference 1:
Relationship to you:
Phone Number:

Reference 2:
Relationship to you:
Phone Number:

Year In School:

Major:

Gender: Male Female

Race:

Are you enrolled or have you been enrolled in the Twenty-First Century Scholar Program?
Yes No

Are you a first person in your immediate family to attend college? Yes No

Are you currently covered by health insurance? Yes No

Please add an emergency contact: (This is who we will contact in case of emergency)

Emergency First Name:

Emergency Last Name:

Relationship to You:

Emergency Phone:

Emergency Cell:

By checking the boxes below, you are agreeing to the following statements.

I hereby certify that the information provided in this application is true and complete.

By submitting this application, I am aware that College Mentors will run a criminal history background check and sex offender registry check on me.

I acknowledge that College Mentors can deny my application to mentor for any reason.

I give permission to College Mentors and my chapter to use any photos or video footage of me taken while participating in this program, or written quotations from me for promotional purposes of the program.

I understand that College Mentors, is not responsible for anything I decide to do to aid an injured person while participating in a College Mentors activity or for anything that happens to me personally.

I will not hold College Mentors or any of its partners accountable for any injuries or pains that may occur during the activities. I understand I am participating on my own free will and therefore College Mentors or any of it partners are not responsible for any injuries or pains that may occur.

Thank you for your interest in College Mentors. We will be doing a limited criminal history background check upon receiving your application form.

212 West 10th Street, Suite B260 Indianapolis, IN 46202 P: 317.921.1798 F: 317.921.1799 Toll-Free: 1.877.473.2635