Thank you for agreeing to work with us as we affect change in our students' personal, social, and academic lives. Please complete the following application form and proceed with the Background Check procedures. We will contact you shortly to schedule your interview and orientation.

I am applying for:

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* 1. I am applying for:

Today's Date

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* 2. Today's Date

Date
First Name:

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* 3. First Name:

Middle Initial:

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* 4. Middle Initial:

Last Name:

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* 5. Last Name:

Are you a REACH Memphis (Memphis PREP) Alum?

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* 6. Are you a REACH Memphis (Memphis PREP) Alum?

Date of Birth:

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* 7. Date of Birth:

Date / Time
Gender:

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* 8. Gender:

Please indicate your t-shirt size.

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* 10. Please indicate your t-shirt size.

Email Address:

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* 11. Email Address:

Address:

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* 12. Address:

City:

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* 13. City:

State:

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* 14. State:

Zip Code:

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* 15. Zip Code:

Home Phone:

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* 16. Home Phone:

Cell Phone:

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* 17. Cell Phone:

Driver's License Number:

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* 18. Driver's License Number:

Make of Car:

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* 19. Make of Car:

Car Insurance Policy Number:

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* 20. Car Insurance Policy Number:

Emergency Contact:

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* 21. Emergency Contact:

Current Employer:

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* 22. Current Employer:

Position Held:

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* 23. Position Held:

Company Phone:

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* 24. Company Phone:

College 1:

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* 25. College 1:

Degree 1:

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* 26. Degree 1:

Graduation Date 1:

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* 27. Graduation Date 1:

College 2:

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* 28. College 2:

Degree 2:

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* 29. Degree 2:

Graduation Date 2:

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* 30. Graduation Date 2:

College 3:

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* 31. College 3:

Degree 3:

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* 32. Degree 3:

Graduation Date 3:

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* 33. Graduation Date 3:

Reference 1 (first and last name):

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* 34. Reference 1 (first and last name):

Reference 1 Phone:

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* 35. Reference 1 Phone:

Reference 2 (first and last name):

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* 36. Reference 2 (first and last name):

Reference 2 Phone:

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* 37. Reference 2 Phone:

Reference 3 (first and last name):

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* 38. Reference 3 (first and last name):

Reference 3 Phone:

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* 39. Reference 3 Phone:

Languages Spoken Other than English:

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* 40. Languages Spoken Other than English:

Were you among the first generation in your family to receive a Bachelor's Degree?

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* 41. Were you among the first generation in your family to receive a Bachelor's Degree?

Hobbies/Interests:

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* 42. Hobbies/Interests:

What does mentoring mean to you?

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* 43. What does mentoring mean to you?

Were you ever mentored?  If yes, what was the experience like?

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* 44. Were you ever mentored?  If yes, what was the experience like?

Why do you want to be a mentor and what do you hope to accomplish?

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* 45. Why do you want to be a mentor and what do you hope to accomplish?

I certify that the information supplied above is correct and accurate to the best of my knowledge.  I also give permission to contact references and I agree to complete a criminal background check.

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* 46. I certify that the information supplied above is correct and accurate to the best of my knowledge.  I also give permission to contact references and I agree to complete a criminal background check.

Please indicate your skill level for each of the following:

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* 47. Please indicate your skill level for each of the following:

  Unskilled Skilled Highly Skilled
Writing
Grammar
Editing
Communications
Math
Science
If you could recommend one book for your mentee to read, what would it be?

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* 48. If you could recommend one book for your mentee to read, what would it be?

Please place a check in the box indicating that you understand the following:

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* 49. Please place a check in the box indicating that you understand the following:

T