GOODWILL SUMMER BRIDGE RETURNING MENTOR FORM
Please note that you'll have to complete this application in one seating. You'll need about 15 minutes.

Application Deadline : March 3rd, 2017
START FORM
 
Enter your full name *

First, Middle Initial, Last
 
I identify my gender as... *

 
What is your Ethnicity/Race? *

 
What is your Date of Birth? *

 
Your cellphone number? *

 
How about your work or home phone number? *

 
What is your mailing address? Please use the following format example: 235 Street Ave. Denver, CO 89039 *

 
The following questions are about your education.

 
Highest level of education completed *

Associates Degree, Bachelors Degree, Masters Degree, Or Doctoral Degree
 
Post-secondary school(s) attended *

Please list only schools that you attended for the following degrees: Associates, Bachelors, Masters and/or Doctorate.
 
What was your degree/major in? *

 
Do you speak a foreign language? *

If you do, please list below
 
Emergency Contact Information:

 
Full name: *

 
Relationship to you: *

 
Daytime Phone: *

 
Cell Phone: *

 
The following questions are about your current employment.

 
Employment:

 
Current Employer *

 
Title *

 
Employer Address *

 
How long have you been with our current employer? *

 
Average hours you work every week? *

 
Have you ever been investigated, arrested for and/or convicted of a crime? *

*If yes, please explain in detail:
 
Have you had any significant life changes in the last year? Please explain: *

 
In thinking about matching you with a new mentee(s) is there anything that you want us to consider this year? *

 
Please select the day(s) of the week that would work best for your schedule in the summer: *

Please select all that work for you. This information will be used during the matching process

 
What locations might work for you? *


 
I understand that all the information which I have given and will give to the professional staff of the program may be substantiated. Staff working on the Mentoring Program may examine my employment records and any records of law enforcement agencies that pertain to me. All information will be held in the strictest confidence,
and the information may be used to determine my suitability for participation in the Goodwill Mentoring Program. I understand that the Goodwill Mentoring Program does not discriminate on the basis of race, religion, or sexual orientation. I understand and agree that I am not obligated, if called upon, to perform services of a mentor and
that the Goodwill Mentoring Program is not obligated to assign a student to me. It is also my understanding that it is the policy of the Goodwill Mentoring Program not to release information to anyone, including myself, concerning decisions of non-acceptance. *

     
 
Goodwill values your privacy, and will use the information you have provided only for purposes directly related to your involvement with mentoring or other volunteer programs.By filling your name and date below, you are giving a digital signature that all

 
Electronic signature of applicant: *

 
Date signed *

 
After submitting your application, a staff member from the Post Secondary Success (PSS) team will reach out about what you need to do next. Next possible steps, not necessarily in this order include:

1. You get to skip the Interview!
2. Attend a training
3. Submitting any extra paperwork

Thank you for mentoring with us again!

- PSS team

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