Please fill out the form as completely as possible.
(All fields are required)
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| Personal Information |
| Name |
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| Residence Address |
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City
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Zip
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| Mailing Address (if different) |
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City
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Zip
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| Home Phone |
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Cell Phone |
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| Work Phone |
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Fax |
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| E-mail Address |
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Date of Birth (M/D/Y) |
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| Sex |
M
F
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Marital Status |
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Person to contact
in an emergency |
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Emergency
Phone # |
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How did you hear
about this program?
(check all that apply) |
Billboard
Movie Cinema Ad
Newspaper Ad
Coffee Sleeve Ad
Recruitment Booth
Fundraising Event
Friend
Other
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| Previous residences during the last three years |
| Address |
City |
State |
Dates |
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| Employment history (past 3 years, starting with
most recent) |
| Employer Name |
Supervisor |
Employer Phone |
Position/Title |
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| Can we contact Supervisor or Employer as a reference? |
Y
N
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If no, please explain:
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| Education |
| Highest level achieved |
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| Name and location of school |
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| Legal History |
Have you ever been investigated for or charged with any
offense involving a person under the age of 18? |
Y
N
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If yes, please explain:
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Have you ever been investigated for or charged with any
other offenses within the last 10 years? |
Y
N
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If yes, please explain:
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| Medical History |
| Are you currently a user of illegal drugs? |
Y
N
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If yes, please explain:
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Have you had problems with or been treated for alcohol
or drug abuse within the last five years? |
Y
N
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If yes, please explain:
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Do you have any physical or mental condition that would
limit your ability to be a Mentor? |
Y
N
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If yes, please explain:
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| References (Please list THREE references with
phone numbers) |
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| Name |
Phone # |
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| Background Information |
| How do you hope to help a child in our program? |
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| What do you hope to gain from your mentoring experience? |
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| Hobbies/Interests |
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| Please list any previous experience working with children: |
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Please list any other non-profit organizations in
Sonoma Valley that you have volunteered for: |
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| Personality Traits: (Please check those that describe
yourself) |
friendly
funny
quiet
serious
patient
reserved
talkative
musical
outgoing
athletic
artistic
organized
curious
studious
thoughtful |
| Placement Information |
| Languages spoken |
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| My interest is in helping a child succeed |
Academically
Socially
Both |
| I prefer to work with |
Boy
Girl
Either |
| Age preference |
5-7
8-10
11-14 |
I prefer to mentor at
(check all that apply) |
Flowery (K-5th grade)
El Verano (K-5th grade)
Sassarini (K-5th grade)
Prestwood (K-5th grade)
Dunbar (K-5th grade)
Altimira (6th-8th grade)
Adele Harrison (6th-8th grade)
Sonoma Valley High (9th-12th grade)
Wherever needed |
| Days Available (check all that apply) |
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays |
| Best Times to Mentor |
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| I understand that disclosure of the information that I
have provided in this application will be limited to those employees
of the Sonoma Valley Unified School District (“SVUSD”) and
volunteers who participate in the selection and evaluation of Mentors
for the SVUSD’s Stand By Me Mentoring Program. I further understand
that, if my application is denied, I am not entitled to an explanation
of the reasons for such denial, nor am I entitled to a review of such
action by the SVUSD or its Board of Trustees. I represent that all of
the information I have provided in this application is true and correct
and understand that such information will be relied upon by the Stand
By Me Mentoring Program in considering my application. |
Signature (type full name)
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Date
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