REACH Memphis Mentor/E-Mentor Application

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* 1. Today's Date

Enter MM/DD/YYYY format

Date

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* 2. First Name:

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* 3. Middle Initial:

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* 4. Last Name:

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

Yes

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* 6. Date of Birth:

Enter MM/DD/YYYY format

Date

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* 7. Gender:

Female

Male

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* 8. Ethnicity

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* 9. Please indicate your t-shirt size.

Small

Medium

Large

Other (please specify)

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* 10. Email Address:

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* 11. Address:

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* 12. City:

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* 13. State:

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* 14. Zip Code:

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* 15. Home Phone:

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* 16. Cell Phone:

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* 17. Driver's License Number:

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* 18. Make of Car:

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* 19. Car Insurance Policy Number:

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* 20. Emergency Contact:

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* 21. Current Employer:

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* 22. Position Held:

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* 23. Company Phone:

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* 24. College 1:

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* 25. Degree 1:

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* 26. Graduation Date 1:

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* 27. College 2:

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* 28. Degree 2:

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* 29. Graduation Date 2:

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* 30. College 3:

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* 31. Degree 3:

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* 32. Graduation Date 3:

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

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* 34. Reference 1 Phone:

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

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* 36. Reference 2 Phone:

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

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* 38. Reference 3 Phone:

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* 39. Languages Spoken Other than English:

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

Yes

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* 41. Hobbies/Interests:

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* 42. What does mentoring mean to you?

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

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

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

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

	Unskilled	Skilled	Highly Skilled
Writing	Writing Unskilled	Writing Skilled	Writing Highly Skilled
Grammar	Grammar Unskilled	Grammar Skilled	Grammar Highly Skilled
Editing	Editing Unskilled	Editing Skilled	Editing Highly Skilled
Communications	Communications Unskilled	Communications Skilled	Communications Highly Skilled
Math	Math Unskilled	Math Skilled	Math Highly Skilled
Science	Science Unskilled	Science Skilled	Science Highly Skilled
ACT Prep	ACT Prep Unskilled	ACT Prep Skilled	ACT Prep Highly Skilled

Other (please specify)

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* 47. 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.

Yes

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

I understand that the mentor program involves spending a minimum of four hours per month with assigned student(s).

I understand that I will be required to complete the mentor program orientation and will participate with the student's core and elective curriculum sessions.

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* 49. Please upload a photo of yourself

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File