Existing Volunteer Mentor Form

Section 1: General Information

Estimated time to complete survey is 5-10 minutes. Please complete survey in one session.
Your responses are not saved until you submit the survey in Section III (Page 3).

Personal and Contact Information

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* 1. First Name

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* 2. Last Name

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* 3. Birthdate (MM/DD/YYYY)

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* 4. Gender

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* 5. Are you of Hispanic, Latino, or of Spanish origin?

Yes

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* 6. Which of the following do you best identify with?

Black or African American

Native American

Asian

Native Hawaiian or Other Pacific Islander

White, non-Hispanic

White, Hispanic

Other (please specify)

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* 7. Phone Number

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* 8. Street Address

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* 9. City

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* 10. State

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* 11. Zip Code

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* 12. Email Address

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* 13. What is your Adult T-shirt size?

Small

Medium

Large

XXL

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* 14. Do you have access to reliable transportation?

Yes

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* 15. Please list any previous experience volunteering, mentoring, or working with youth.

Occupation and Education Information

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* 16. What is your occupation?

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* 17. Who is your employer?

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* 18. What is the highest level of school you have completed or the highest degree you have received?

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate degree

Bachelor degree

Graduate degree or Professional degree

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* 19. If you attended college or university, please list the school name and major

School Name:

Major:

School Name :

Major:

School Name:

Major:

Criminal History Information

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* 20. Have you ever been convicted of or pleaded "guilty" or "no contest" to a felony or misdemeanor as an adult or juvenile?

Yes

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* 21. Are you currently charged with a felony or misdemeanor?

Yes

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* 22. Have you been or are you currently being investigated for allegedly abusing, neglecting, or exploiting a child, an elderly person, or a person with disabilities?

Yes

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