Mentor Application for Camp Mariposa

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* 1. Name of Applicant:

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* 2. Nickname (if any):

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* 3. Gender:

Male

Female

Other

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* 4. Date of Birth:

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* 5. Address:

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* 6. Home Phone:

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* 7. Cell Phone:

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* 8. Email:

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* 9. Preferred method of contact:

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* 10. T-Shirt Size (Adult):

XXL

XXXL

Other (please specify)

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* 11. What is you Race/Ethnicity?

African-American

Asian

Caucasian

Hispanic/Latino

Native American

Pacific Islander

Multi-Racial

Other

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* 12. Are you employed?

Yes

Retired

Not working right now

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* 13. If employed, what company do you work for and what is your title?

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* 14. Are you currently enrolled in school?

Yes

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* 15. If in school, where do you attend and what is your major?

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* 16. What languages (other than English) do you know?

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* 17. Highest level of education you have completed:

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* 18. Camp Mariposa location:

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* 19. How did you hear about the Camp Mariposa program?

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* 20. Briefly describe why do you want to be a mentor with the Camp Mariposa program?

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* 21. Are there any conflicts or constraints that might make it challenging for you to participate in the program?

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* 22. Do you have any previous experience with youth who are at risk?

Yes

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* 23. If yes, please provide a brief description of your experience.

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* 24. Do you have any personal or professional experience working with adults/youth/families impacted by substance abuse or addiction?

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* 25. Any special skills we should know about?

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* 26. Have you ever been convicted of a crime?

Yes

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* 27. If yes, please explain below.

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* 28. Have you ever been interviewed by Child Protective Services (CPS)?

Yes

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* 29. If yes, please explain below.

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* 30. Camp Mariposa requires at least two references for all mentors. One of the references must be a professional reference. Please feel free to provide any additional references to help us ensure the completion of your application in a timely manner.
Please include the following: Name, relationship, years known, telephone number, email, physical address, and preferred method of contact.

Reference 1:

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* 31. Reference 2:

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* 32. Reference 3:

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* 33. Reference 4:

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* 34. I hereby certify that the information given on this form is factual and complete. I give my permission for any necessary verification. I release from liability any person and/or this organization giving, receiving, or utilizing any such information in making decisions regarding my application to volunteer.

I agree

I do not agree

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* 35. E-Signature

Full Name

Date of Birth