| Name * |
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| E-mail Address * |
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| Date of Birth |
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| Current Home Address * |
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| Campus Address (if applicable) |
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| Phone Number * |
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| Alternate Phone Number: |
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| Classification (If you are currently a student) |
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| Please list your major and cumulative Grade Point Average |
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| How long have you lived on your current address * |
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| If less than five years, please list all other addresses for the previous five years |
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| Present Place of Employment |
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| How long have you been working there? |
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| Work Address |
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| Work Phone |
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| Name of Supervisor |
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| If you have been with this employer for less than five years, please list all other employers (and their addresses) for the previous five years: |
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| Have you ever been convicted of a crime? * |
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| If yes, list date(s) and charge(s) of which you were convicted: |
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| Do you currently have any criminal charges pending against you? * |
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| If yes, please describe them: |
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| How did you hear about Bridging the Generations? * |
Website
Newsletter
Friend
Faculty
Poster
Other
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| Have you ever been a mentor? * |
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| If yes, where and for how long: |
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| Why do you want to become a mentor? * |
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I enjoy playing sports
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| Please list the sports you like playing |
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I enjoy outdoor activities
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| Please list the outdoor activities that you enjoy |
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I enjoy games (board games, card games, video games, chess, etc)
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| Please list the kind of games that you enjoy |
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I enjoy arts and/or crafts
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| Please list your special interests and skills in arts and/or crafts |
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I enjoy computers and other technology
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| Please list your specific interests and skills in computer and technology |
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| Please mention any other interests that you have |
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| Do you have other special skills and experience? (e.g. knowledge of sign language, expereince working with adolescents, experience helping children learn to read) |
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Are interested in serving in the Chess Program
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Are you interested in Saturday mentoring?
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Are you interested in Book Club?
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Are you interested in Sports program?
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Are you interested in Cooking Program (Coatesville, PA)
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| Do you have any membership affiliations? |
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| Please list the organizations/ groups that you are affiliated with |
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| Are there some types of children or youth whom you would prefer to mentor- or for whom you feel you would be particularly successful mentor? (e.g shy people, someone with learning disability, someone with physical disability, someone who loves sports, someone who loves to draw, someone with anger problems) |
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| Are there some types of children or youth with whom you might have difficulty or would prefer not to mentor? |
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| What kinds of support and assistance can the program offer that will be most helpful to you? |
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| Please list the names, address, and phone numbers of three people you want to use as references. They must be people who have known you for at least one year. (Please do not list relatives) * |
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| What would you like to do with a protege/mentee? * |
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| Do you speak a foreign language? |
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| If yes, please specify |
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| Write a brief statement on why you have chosen to participate in the mentor program: * |
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| What days of the week are you available to volunteer? (Check all that apply) |
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Sunday
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Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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Saturday
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| What is the best time for you to volunteer? (Check all that apply) |
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Mornings
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Afternoons
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Evenings
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Weekends
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